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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> W: • r <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> a o <br /> SITE L' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PEENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEA EST CROSS STRE ✓So to in4icate Cl PARTNERSHIP El 'All AGENW IV <br /> ❑ NDMDULGN 11❑ COUNTY AGENCY <br /> L AGENCY ❑ FEDERAL AGENCI <br /> W <br /> CITY NAME STATE ZIP CODESITE PHONE N WITH AREA CODE <br /> CA Sa:f 2 209-53 -0 28 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK'# <br /> ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST HANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,Kvii'(.(.e/1 Tl�'�'ie s &ONE#WITH AREA COD DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 5 AiwLs 1C > �31-07 2 3 -6-7 2-f <br /> NIGHTSNAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> Z K '7 Beed 3/-D 2 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME c _ _ .-I CLeR S�-M e C CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS - !J ,_1 / �✓Bo Ao intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 6 (j IRS <br /> ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> G INDIVIDUAL 11 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> IL � P� �. OL A- <br /> MAILINGorSTREETADDRES ✓Box to,naicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 6 p p �p e PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> a C/ F-'f!/ alINDIVIDUAL ❑ COUN Y-AGENCY <br /> CITY NAME S7(� / ,JSTATE ZIP C 7 PHWITH REA C0� <br /> IV. LEGAL NOTIFICATION'/A�/NDD BB'`IING ADDRESS L//'�J— �/j <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 /> A IGANT'S NAME(PRINTE SIGNATURE) DATE <br /> r9/8s' <br /> LOCAL A EN USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> M 10 D 1 A o o 1 1 (9 1 () d 1 3 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WFfH AREA CODE <br /> MI (_,e, 7, <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO O CENSUS TRACT# SUPERVIS"ISTRICT CODE BUSINESSPUN FRED NO <br /> ❑ DATEELED <br /> 2 <br /> CHECK# PERMIT AMOUNT SURCHAR E AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM M ST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> taw DATA PROCESSING COPY lilawall "`x S <br />