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STATE O C LIFORNI WATER RESOURCES CONTROAARD sE <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> e1bfAJ r kf Tu- REST Rr <br /> ADDRESS NEAOSS STREET ✓9ml-WuW D PARTNERSHIP D STATE-AGBICY <br /> 526 ♦ D CORPORATION D LOCALAGDIcr D FEOBML-AGPICY <br /> tr4 /'�'� D INDNO W D muxn-AOela <br /> CIN NAMESTATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> 0ekhW <br /> CA 9��os— zo -?w i5a/ <br /> TYPE OF BUSINESS: ❑ 2DISTRIBUTOR PROCESSOR ✓Boz if INDIAN EPA ID N <br /> RESEE] i GAS STATION ❑3 FARM L'J "OTHER TRUSTYLANDS ur ❑ AT THIS SITE <br /> oZ— <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> S 150 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e( JIIL, <br /> MAILING ar STREET ADDRESSV f7 ✓Boz to ieoicale D PARTNERSHIP D STATE-AGENCY <br /> a'X /ID -/ D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME� STAT ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM? �IlII/1/ - CARE OF ADDRESS INFORMATION <br /> /�/ WN JLKi <br /> MAILING or STREET ADDRESS ✓Bon to inolcale D PARTNERSHIP D STATE-AGENCY <br /> QD CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> V D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAMEZIP CODE PHONE N,WITH AREA CODE <br /> O er^ STATE 5 2O <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDIIIBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL 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 /> ,be d yyo,?,qW7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION R AGENCY N FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> F/.coys <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR•DMTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3,� z5__ YES [] NO A/' P/ <br /> CNECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> e7",(- <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 <br /> � 1 <br />