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i A <br /> STATE OF CALIFORN6w� WATER RESOURCES CONTROLU BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PER��.4ED SITE F"a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> 00 <br /> FACILITY/SITE NAME VY✓ CARE OF ADDRESS INFORMATION <br /> AD3ESS3l /T�� `/(l• STC I`.GC ✓ IoiiWicele ❑ PAUNLOCAL GEN ❑ STATE <br /> `fid �/.J( WHP0R1t10N Cl LOCAL AGENCY ❑ STATEAGENCYCY <br /> 0 worvmwL 0 COUNTY AGENCY <br /> CITY NAME77"� STATE ZIP CODE SITE PHO N. ITH AREA CODE <br /> TU G� rJv� CA 0 5 (do 131—5644 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 CESSOR ✓Ror It INDIAN EPA ID p <br /> TAINKs <br /> RESERVATION or AT <br /> HIS SI <br /> ❑ 1 GASSTATION ❑ 3FARM 5OTHER TRUST LANDS 1:1 <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE ft WITH AREA CODE <br /> aOCI 931 -6 as3 S <br /> NIGHTS: NAME(LAST,FIRST) PHME#WITH AREA CODE NIGHTS: NA (LAST,FIRST) PHON WITH AREA CODE <br /> S - <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME T CARE OF ADDRESS INFORMATION <br /> MAILINISTREE1 AUDY41L15S <br /> C'4' _N/ to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /� 7 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME it STA ZIP CODE PHONE It.WITH AREA CODE <br /> -v <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ( Y i <br /> MAILING or GfREET ApORESS ✓ to ind ate ❑ PARTNERSHIP 0 STATEAGENCY <br /> NY ORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> P D. It 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PH NE#,WITH AREA CODE <br /> S C '14 - (ao 3/—LiWo <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS d. :5 OJ <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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY R FACILITY ID M R of TANKS at SITE <br /> = = jclj61j1jzjjajl1 101a10111_ <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROV BY M PHONE N WITH AREA CODE <br /> PERMIT NUMBE PERMIT OVAL DATE PERMIT EXPIRATION DATE <br /> [C±HECf <br /> DE CENSUS TRACTN )SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D <br /> YES ❑ NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM Y: <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 ONLY. <br /> FORM�10(3-2-811) J <br /> I 0 A taw DATA PROCESSING COPY <br />