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STATE OF CALIFORNIA WATER RESOURCESCONTROBOARD <br /> FORM `Aa: UNDERGROUND STORAGE TANK PROGRAM = " zo <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> lJ COMPLETE THIS FORM FOR EACH ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 NTLV�� SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 11 '7D <br /> 1. <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAM CARE OF ADDRESS INFORMATION <br /> 0 P T"iG <br /> ADDRESS NEAREST GROSS STREET P D STATE AGENCY <br /> ORYONATION Cl ei El LOCAN AG NCY ❑ FEDEPM AGENCY <br /> ' v I,rz ❑ INOMOUAL ❑ COUNIYAGENCY <br /> C�1 STATE A ZIECOD� �.� SITOt' k,WJ,TH A? A_C <br /> CITY NAME O[J�OQ <br /> r K- CA Y s' G/J G/1/7/ (7/ <br /> TYPE OF BUSINESS: EPA ID If <br /> ❑ 3FARMIBU70A 5 TOCE5S0A RESERVATION or If of TANK'a <br /> ❑ 1 GAS STATION ❑ 3 FARM 55 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> F PHONE p WITH AREA CODE OAVS. NAME(LAST FIRST) PHON N WIT <br /> AREA CODE <br /> DAYS NAME(LAST.FIRST) 42 ?�y� /cla �' /� �1 �/C� <br /> M /W%• 14 PHONE p WITH AREA CODE NIGHTS NAME /I R�S/TIIY PHONE7p WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIR ) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> ♦' X11 T�� CARE OF ADDRESS INFORMATION <br /> NAME 1'� r A 5-f/Z06ti V J- <br /> LMAILINITREETADD'R551 ON to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> l � � tjAV. CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> '//� 12 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE - ZIP CODE PHONE p,WI'TH.A C DE <br /> III, TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME /, -�_Q <br /> MAILING or STREET ADDRESS ✓Box to indri ❑ PARTNERSHIP LlSTATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE p.WITH AREA CODE <br /> CITY NAME <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> CO� JURISDICTION <br /> � AGENCY# FACILITY ID% Mol TANKS at SITE <br /> UG / s" Ou0 <br /> C CURRENT LOCAL AGENCY FACILITY IDK APPROVED BY NAME PHONE N WITH AREA CODE <br /> EST 73 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION ODE LLLL2 <br /> SUPERVISOR-DISTRICT CODE BUSINES�SN FILED NO ❑ DATE <br /> a <br /> O � <br /> CHECK M UNT FEE CODERECEIPT k <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM rB' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) _ .Aa <br /> DATA PROCESSING COPY `AE <br />