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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C/ COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION P LY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE V <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L'/7Y O F T� Re6 's-ro ►o n/ a CW7t <br /> ADDRESS / /�, _1 �/(�� N EST CROSCSS EET ✓&vroirdn@ ❑ PARINENSIIIP ❑ STAi6AGENGY <br /> So' f. ✓RR7�/T�IIv • "� ` ❑ IN�DN�Ig1ALl� ❑5ml COUNIY AGENCY 13FFDER4L-AGENf.Y <br /> CITY STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA �� _76 0 - 836 - a67o <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑d PROCESSOR I ✓Box if INDIAN EPA ID NRESE / <br /> If of TANK's <br /> E] I GAS STATION E] 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION o ❑ umt� ODO V V I6 V 3 AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) - <br /> D NAME(LAST FIRST) #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> It3 � /�� <br /> 1O•J 20CC - PHONE- J 10 <br /> NI TS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> as " ao - 164 4o <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r C <br /> MAILING or STREET ADDRESS ^ %/Box to indicate .Fr�T PARTNERSHIP ❑ STATEAGENCY <br /> S A \,,L _0 11 CORPORATION 422-LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> Cl INDIVIDUAL L❑J COUNTY-AGENCY <br /> CITY NAME_ �� STQTE ZIP CODE PHONE It,WITH AREA CODE <br /> O <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) 3 <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADD# RQ ✓Box to indicate PARTNERSHIP Cl STATE-AGENCY <br /> �J> YD • ❑ CORPORATION JOLOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITYNAME STA ZIP ODE PHONE N,WITH AREA CODE <br /> C` 6� , 3-7 L <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ 111.X <br /> THIS FORM HAS BEEN COMPLETE UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> PP CeA 'SNA (PR E &SIGNATUREI DATE <br /> q a8-g°r <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCYN, FACILITY ID It N of TANKS at SITE <br /> C70 1 / 14/1 a I 10 0 0 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER qP61MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE FILED <br /> D Z 'y a 3 Z YES ❑ NO ❑ 10 Z-g <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY: I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL <br /> FORM A(3-2-88) <br /> ^'' DATA PROCESSING COPY w <br />