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STATE OF CALIFORA WATER RESOURCES CONTROL BOARD ' <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM uP ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ni <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Sl G <br /> Q' <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) p <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Gl Ile,— Obi l AEj I <br /> ADDRESS _ NEAREST CROSS STREET I/Box to inmcale 11PARTNERSHIP El ST E- <br /> AGENCY <br /> 3(o s Z OU/Se 4✓e - ❑ CORPORATION 13 LOCAL AGENCY 11FEDERAbAGENCY <br /> / i ZBGS ❑ INDNIIDUAL ❑ COUNIYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 0.WITH AREA CODE <br /> L-GzCA <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID a <br /> F__] 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTRESEVAT THIS <br /> SITE <br /> AIRON� ❑ <br /> AT TE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AR CODE <br /> e 1192 8 g -ytis <br /> NIGHTS: NAME(LAST.FIRST);l WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> l' � r <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY. <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> u6--gym UY3a <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STR ADDRE S ✓Box to in4icale ❑ PARTNERSHIP El STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> '1I- fVIK-12Y Jb <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. ❑ 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 R AGENCY A FACILITY ID# R of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE <br /> �vc3�, <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> z 3 �9-0 30i{p YES NO <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY. �x g�A <br /> ass <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST*MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. -� <br /> FO M A(3-2-88) ` <br /> 0 DATA PROCESSING COPY <br />