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STATE OF CALIFORNIA' WATER RESOURCES CONTROLBOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE C � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENJ 1_01EDSITE FJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> FAC ILI SITE AME CARE O ADDRESS INFORMATION <br /> SPit/-�CIS J ; ,q <br /> ADDRESS I13 PMiNDSHP 11 STATE AGENCY✓ adnPLGN O �AG� ❑ FEDERAL-AGENCYa <br /> 11 <br /> CITY NAME O I� STATE ZIP COpE/�/ E�HO N.WITH AREA CODE <br /> TYPE OF BUSINESS:(/ __j 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID xof TANICS <br /> ,. / <br /> ❑ 1 GAS STATION ❑ 3 FARM �OTHEfl TRUSTYATION LANDS or ❑ ((/ AT THIS SITE C� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAM (LAST,FIRST) PHONE WITH AREA CODE <br /> 1�✓u�QR. W � Civ � � 4 - s-r,� I S� 3'�4 <br /> NIGHTS'. NAME f, T,FIRST) PHONE a WITH AREA CODE NIGHTS IN ME(IAST,FIRST) PHONE WITH AREA CODE <br /> 11. PROPERTY OWN INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAM CARE0 DRESS INFORMATION <br /> MAILING or STREET ADD ESS <br /> ESSS (']/�D' ( ( rw to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> I BNS `"— •.�/�-�� Z U Z ' T L❑7 INDIVIDUAL ION 11 LOCAL-AGN CY p �B FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> t CA Iy 5 ?7- gt(. <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME (Jw �`-' CARE I�DRESS INFORMATION <br /> 8 1111til <br /> MA/fJ�IN ,or TREET ADDRESS ✓ 1-indicate ClClPARTNERSHIP 13STATE-AGENCY <br /> LCl COUNTY AG NCYION FEDERAL-AGENCY <br /> 11 INDIVIDUAL <br /> CITY NAME ST TE ZIP CODE PHONE N,WITH AREA CODE <br /> S TnG � (A '7g7 <br /> S Zd - 301 s i <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> CNTY W JURISDICTION If AGENCY F FACILITY ID R N of TANKS at SITE <br /> rn <br /> ° � U 10l z0 10O ID <br /> CURRENT LOCAL AGENCY FACILITY ID Jr APPROVE 0 NAM PHONE N WITH AREA CODE <br /> ftti �=c <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERV R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3T ( YES NO <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <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 A(3-2-88) - <br /> '61 \.., DATA PROCESSING COPY vMl( <br />