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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD' <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = � o <br /> SI FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /D <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) to <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L-4 0 Sfo GIC�a,I -W1 i Q�C(fi if r ry <br /> ADDREUJNEAREST CROSS STREET ✓Rt,ebcax ❑��� PyyRRNEACHIP ❑ STATE AGEIW <br /> /� ��w y, /B .,L,� Cliff" {, ❑ CORPORATION Ly'LOGLAGENCY ❑ �EDERALAGENCY <br /> K /IE �� /J Q l.i O[(/)'J I I' +/ ❑ INDIVIDUAL ElCOUNN�AGENLY <br /> CITY NAME STATE ZIP CODE ITE PHONE p,WITH AREA CODE <br /> '540 CA pao9 9�t�-87/S <br /> TYPE OF BUSINESS: F-12 DISTRIBUTOR �❑ 44PTHER PROCESSOR ✓Box if INDIAN EPA ID #RESEI y� <br /> ❑ ❑ 3 FARM O 5-: TRUSTYLANDS cr <br /> 1 GAS STATION ❑ //V D/[ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Qo►v Kinj 6907 q'fY-9-71-5 <br /> NIGHTS'. NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 9 WITH AREA CODE <br /> S'arnr° <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> D SloI -diun i c ipa y it <br /> MAILING 01'1&fREET ADDRESS ✓Box to indicate ❑ PggRTNERSHIP ❑ STATE-AGENCY <br /> /`l �) ❑ CORPORATION ��COCAL-AGENCY ClFEDERAL-AGENCYS L(/� ✓�/ V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE u.WITH AREA CODE <br /> G G14 <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Saw 4S r uJh�r <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCYCl FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <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. ❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# It o1 TANKS B1 SITE <br /> ® � 0 / da 16100 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> )'YlithO � <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT U# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE F(�IL.ED¢p� <br /> Q <br /> ,),319-0 9, YES [-] NO $ 7 O O <br /> CHECK At PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . <br /> FORM A I3-2-88) <br /> B/ DATA PROCESSING COPY <br /> r..r <br />