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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Z <br /> SITE i FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> Ii <br /> MARK ONLY ❑ 1 NEW PERMIT F-] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY�T D SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE Lj U - <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) M <br /> FACILITY/SITE NAME CARE ADDRESS INFORMATION <br /> W S' Ti1u�r/ <br /> ADDRESS ./ NEAREST CR SS STREET ✓ mn4eate ❑ PA)11NFH91P STATE AGENCY <br /> O }N PORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> / /YD ❑ INOMOUAL ❑ COUNIY AGi <br /> CITYNAME STA E ZIP CODE SITE PHONE N,WITH AREA CODE <br /> S cA O ! sg�6 <br /> TYPE OF BUSINESS-. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID/N,` M of TANK'# <br /> �L RESERVATION or u h AT THIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM I OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. SAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS.ANAME(I FIRST) PHONE k WITH AREA CODE <br /> e er E. 2a4 -Y 14 <br /> NI HTS'. AME(LAST,FIRST) PHONE N WITH AREA CODE NIG NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I�e z ?_ K/LV/ <br /> 11. PROP RTY OWNER INFORMA ON & ADDRESS - (MUST BE COMPLETED) <br /> NAM 11 CARE OF ADDRESS INFORMATION <br /> Q� -ro)"046 6*767 <br /> MAILING or ATREET ADDRESS ��✓�ox to intlicale EI PARTNERSHIP ❑ STATE-AGENCY <br /> A /J�CORPORATION El LOCAL-AGENCY ElFEDERAL-AGENCY <br /> DIVIDUAL Cl COUNTYAGENCY <br /> CIN NAME ST�TEZIP CODE � Pi ��y�_J^ <br /> N,WITH AREA <br /> i 4 %y6 <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BGE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SAME T4s' <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I] INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <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: LPI 11. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION K AGENCY N FACILITY ID R R of TANKS SI SITE <br /> ® = = 1010 .2 1 O a 11) <br /> CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE Al WITH AREA CODE <br /> 6 ' <br /> PERMIT NUMBER PERMIT APPROVAL DTE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT it SUPERVI OR-DISTRICTCODE BUSINESS PLAN FILED DATE FILED <br /> 23> 2(/ YES NO ❑ �1 / u <br /> CN CK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> �/ DATA PROCESSING COPY `F <br />