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STATE OF CALIFORN A WATER RESOURCES CONTAtft BOARD ��' <br /> St� Thf <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ��" <br /> S FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - m �; o o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITErl� `'��F�a"-`" <br /> ARK ONLY F__] 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENT SITE F"B' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT Eln 6 TEMPORARY SITE CLOSURE _I I N <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> C71 <br /> FACILITY/ TI(DAME <br /> � CAR40FDDREBB INFORMATnNAojf `f^ � >g Ta( <br /> ADORESJNFARESTCROSS STREET <br /> ✓Bmbnim ❑ PAUNE9IP ❑ STATEAGENLY <br /> },�11 !1 /� ,1y, / ,.. ❑ CDAPgl4nON Ibrnn���#GENCY ❑ FEDERAL AGENCY <br /> F' • `Q� ( cL C- "�^' �'�•r'n'� ❑ INDIMIJ& LI fAUN1Y-AGENCY <br /> CITY NANF, STATE <br /> CA ZIP' <br /> SITE N,gHAREA. <br /> O /O9 <br /> F—]TYPE OF BUSINESS: p DISTPoBUTOR F—] 4 PROCESSOR ✓Box it INDIAN EPA ID N 9 Y <br /> RESERVATION or R of TANICS <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Y-1 <br /> E7N <br /> NIGHTS: NAM (LA ,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> fFMn <br /> II. PROPERTY OWNER INFORMATI N & ADDRESS - (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> � I1 0� Shxk+an Robe monk <br /> MAILING or STREET ADDRESS -/Box to in0icate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> � 5 ❑ CORPORATION &'LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> oZ , 1 or ado ' (Yl 31 a� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE N.WITH AREA CODE <br /> ��(DY, - 95 ae a aoa q Ll : <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMEC 1,t" <br /> 3 Ilam( ,�1(<fM fC CARE ,ADDRESS(FORMATION <br /> AILINGor STREET ADDRESS ✓KBox11Va_iir,mioate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /'� ❑ CORPORATION &TOCAL-AGENCY 11FEDERAL-AGENCY <br /> ( 1 1"� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STgT♦: ZIP CODE �o; PHONE p,WITH CODE l I <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS (`Sly (-]`5 yl GGvI I <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ET�111.❑ <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 /> COUNTY R JURISDICTION# AGENCY# FACILITY IDR #o ANKS at SITE <br /> U 1 ct Lbjb 10 1I <br /> CURRENT LOCAL A NCY FACILITY IDN APP PHONE N WITH AREA CODE <br /> �l G //\/ O <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CO(E CENSUS TRACT,I SUPERVISOR- STRICT CODEv� BUSINESS PLAN❑FILED NO <br /> ❑ DATE FILED cu) <br /> CHECK#r�'�J PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 /> 1 FORMA(3-2-88) <br /> DATA PROCESSING COPY 5 <br />