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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': "T <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C4^IFOa�MrP <br /> A COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> tJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE V <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACIUTYYSITE NAME CARE OF ADDRESS INFORMATION <br /> Gll/A1C#/a-b fi�vfl_II <br /> ADDRESS NEAREST CROSS STREET ClCI CDRMRATION ❑ LOCAL EA AGENCY ❑ FICHip El EDERATE AL AGENCY <br /> AGENCY <br /> /�7 ,� Al- AD A0� ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> //(/ ��F.`//� /'� STATE ZIPCODESITE PHONE#,,WITH AREA CODE J� <br /> CITY NAME S Z—CJ�-f— , ✓A CA l 1l0 1 (�) qui L _ O� <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # !/ If of TANK'# <br /> 5 RESERVATION or ❑ AT THIS SITE O <br /> ❑ 1 GASSTATION ❑ 3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> G/lINCN�oGD A,vd V Cyoq ) 46z- 56V0 <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,--Hi FiP-L) IF�i Co . <br /> MAILING ar STREET ADDRESS ✓Sox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0- �Q ./x ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE (fHONE#, 'WIIT//H AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> G N G Reil c - <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOGAL-AGENCY [IFEDERAL-AGENCY <br /> XlLD _ w-+ [IINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> c�4 qs�1 2,) X162£ss�/O <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(7)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El 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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION If AGENCY# FACILITY ID N If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID At APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SU RVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FI D <br /> 0 Z 3 ,� Z_3 YES [-] NO [-] / 7/q ( <br /> CHEECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> F 7as <br /> - <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST III OR MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. „ I <br /> FORM A E3 2-883 <br /> \ DATA PROCESSING COPY '.� IN, <br />