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STATE OF CALIFORNO WATER RESOURCES CONT BOARD r y <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM q <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION It <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'<son <br /> MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ®.7 PERMANENTLY CLOSED Si <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE <br /> t <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> A( ap Farm eud eNC tJ <br /> ADDRIEdIS N AREST CROSS STREET ✓�a to irclome D PARTNERSHIP D STATE AGENCY <br /> �'60RPOUTION D LOX AGENCY D FEDERAL AGENT <br /> D worvlouAL D COUNTr-AGENCY <br /> CITY NAME A STATE ZI CODFSITE PHCI E#,WITH AREA CODE <br /> L o <br /> CA 2�' S -218e <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ry 4C PROCESSOR ✓Box if INDIAN EPA 0/ate #of TANK's <br /> RESERF-11 GAS STATION ❑ 3 FARM LA OTHER TRUSTYLANDS ATION of ❑ Uk.h/ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) p, /I PONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> P_NOcI N &C� ` - ^2'76( Q k IJ <br /> NIGHTS. NAME(LAST,FIRST) ONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> P� uden� oCr _2 6 IcN <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ME AS -r <br /> MAILING or STREET ADDRESS %/Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL AGENCY D FEDERALAGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME . CARE OF ADDRESS INFORMATION <br /> Rlposi (Fa Service. <br /> MAILINGor STRELTADDRESS ✓Box to indicate D PARTNERSHIP D STATE AGENCY <br /> D <br /> O CORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> C' A7 O D INDIVIDUAL D COUNTY-AGENCY <br /> CITY AME ` STATE ZIP CODE P ONE#,WITH AREA CODE <br /> t ory C 9536E 2� —2(88' <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. ❑ II. ❑ 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 IT #of TANKS at SITE <br /> 10101 / 16101S1 CSO <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE#WITH AREA CODE <br /> NO <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED n is <br /> S 23.80 YES NO ❑ II <br /> CHI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPUCATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />