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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD %s` � '.". <br /> FORM `A': d�.�,, , `s, <br /> UNDERGROUND STORAGE TANK PROGRAM = � m <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION e, Z <br /> 7 COMPLETE THIS FORM FOR EACH ACILITY/SITE `+�„o;a�> to <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E95 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT4 AMENDED PERMIT <br /> ❑ ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> F ILITY/S;NA CARE OF ADDRESS INFORMATION <br /> AD ESSr " I r6ou5L Sales <br /> I//f 'may/ G /y�yCl! /0 EAREESSTTCCR/O..SSST EET ✓Bnt NinAioKa 0 PARTNERSHIP 0 STATE-AGENCY <br /> V �1 V 1 [ I LWL.II Q 0 CORMIRIALoN ❑ LOCAL-AGENCY <br /> ❑ FEDERAL-AGENCY <br /> CITU M <br /> -oGK a/1 STATE ZIP CODE_ SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS: []2 DISTRIBUTOR [:]4 PROCESSOR ✓Box if INDIAN EPA ID # 9 4 <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER It of TANKs <br /> TRUSTYATION LANDS Dr ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LASTFIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONEp WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to ini icale 0 PARTNERSHIP 0STATE-AGENCY <br /> 0 CORPORATION 11 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indtcale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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. ❑ 11. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 1 <br /> 39 pOf- E � p i <br /> CURRENT LOCAL AGENCY FACILITY ID 051PPAOVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PEA <br /> RMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 11,^` <br /> V` <br /> LOCATION CODE CENSUSTR CTO 2 <br /> # SUPERVISOR-DISTRICT CODE BUSINESSPUN❑ HG FILED ❑ DATE FILED <br /> 0` v` Z3 3 <br /> CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# ` <br /> ` THIS FORM MUST BE ACCOMPANIED BY AT LEAS""`lR MORE TANK PERMIT FORM 'S'APPLICATION(SI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. tJ <br /> ..\Y FORM A S 2-88) 1. <br /> DATA PROCESSING COPY `�/ <br />