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IC1c1 -G3o d� <br /> STATE OF CALIFORN19 WATER RESOURCES CONTRCOOARD <br /> FORM `A': ,. 1 <br /> UNDERGROUND STORAGE TANK PROGRAM V <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACT ITY/SITE <,FoaNtP <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> OV I ,(n l <br /> ADDRESS NEAREST CROSS ST ✓&P to ivlicate ❑ PAATI=IWP ❑ STATE AGENCY N <br /> Ll❑ MRPO�TION [ ENNY ❑ FEDERALAGENCY -w <br /> CITY NAME STATE ZIP COD F SITE PHONE#,WITH AREA CODE y/ <br /> 19 C /1 <br /> CA — cl 9g�-5,7-b <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR+ ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ 1v VATION or #of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST( PHONE p WITH AREA CODE DAYS: NAME(LAST.FIRST)- PHONE k WITH AREA CODE <br /> Cjyyl u c/ - -2275- }CC�y� 2 0 E( -u7% <br /> NIGHTS'. NAME(LAST, RST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIR T) PHONE#WITH AREA CODE <br /> Ct 3 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 'T}il1 zJ U rJ <br /> MAKING or STREET ADDRESS ✓Box to iLl n4lcale Cl PARTN IP ❑ STATE-AGENCY <br /> I ' D DD� ❑ NDMORATION ❑ LOUNTV AGENCY ❑ FEDERALAGENCY <br /> CITY NAM STATE ZIP DE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME +tJ, '^ CARE OF ADDRESS,NFORMATION <br /> DIT 1 <br /> MAILING or STREET ADDRESS ✓Box to,ndroale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �'` ❑ CORPORATION ❑ g�LAGENCY 13 FEDERAL-AGENCY <br /> 1 `J ❑ INDIVIDUAL &PSOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE <br /> 4,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. ❑ if. ❑ 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 Is AGENCY# FACILITY ID# #of TANKS at SITE <br /> 0 1 d O I to I 6 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> V OI <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DIST CODE BUSINESS PLAN❑FILED ❑ DATE FILED (((yyy <br /> \ 23 (O�L/� YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> VVV 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 /> 0 DATA PROCESSING COPY <br />