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bra+ �,.- ... <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM "° ro' <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> I�E COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I If <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) r <br /> N <br /> FACILITY SITE NAME CRE OF ADDRESS INFORMATION <br /> C emen}� -Ra C l -'t o �oX 6-Y 9 . Lodi <br /> ADDRESS OD E NEARES CROSS IS Cl <br /> El❑ LOCAL AGENCY <br /> ❑ STATE AGENLy <br /> 1 -7 Irn/µ I 11 ❑ COAPOAATION ❑ 1pCpl gGENCY ❑ FED <br /> EMI AGENCY <br /> INDIVIDUAL D CGUNWAGENCY <br /> GITy NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE <br /> �`\/ICn�F,M1 CA 75 1209 -7,59- 3 5 3 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID X <br /> ❑ ESERVATION <br /> I GAS STATION ❑ 3 FARM 5 OTHER TRUSTT LANDS or El AT <br /> of TANK'# <br /> AT THIS SITES i <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE p WITH AREA CODE <br /> hl�vinOre. (dOW -07 O i <br /> NIGHTS: NAME(LAST.FIRST) PHONE X WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> 48-rr0-ld 33 -0.7 d <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMEC axkA e, C. vJOOCARE OF ADDRESS INFORMATION <br /> d <br /> MAILING or STREET ADDRESS I- I/Box to indicate D PARTNERSHIP Cl STATE-AGENCY <br /> } , Lam,/y�j�_ ` C�. ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> li ll//i �� 1� O ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X,WITH AREA CODE <br /> L f (2h I 95aq,o X04) 334-6-296 <br /> Ill. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ® it. ❑ Ill. ❑ <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 R AGENCY X FACILITY ID# #of TANKS at SITE <br /> 3 9 0 0I / ITTIlI lololoial <br /> CURRENT LOCAL AGENCY FACILITY IDX APPROVED BY NAME PHONE#WITH AREA CODE <br /> eM e 17 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT X SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED p <br /> (o YES NO �S p 9 <br /> CHECK# 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-BB) <br /> DATA PROCESSING COPY <br /> I <br />