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If <br /> STATE OF CALIFORNO WATER RESOURCES CONTO BOARD <br /> 1 , <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM " Z <br /> S7MARK <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SED ITE M"a <br /> ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> co <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> GLorn /'uG /`'vL <br /> ADORES NEAREST CROSS STREET ✓Boil injue ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> e/IO P ❑ INDIVIDUAL ❑ COUNIYAGENCY <br /> CITU NAME STATE ZIP ODE TE PHONE N.WITH AREA CODE <br /> CA fiSa� Sao9 -5�0 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I '/So.if INDIAN EPA ID ftRESEATION ,t <br /> ❑ 1 GAS STATION ❑ 3 FARM �THER TRUST LANDS Or r-1 <br /> /v D YI�� AT THAS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) p� (p PHONE[#�WIIT/H�A�R{EA CODE DAYS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE <br /> SM14k. 6�t /&4r 7 <br /> NIGHTS: NAME(LAST FIRST) PHONE If 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 /> DIII 7"r u c, lC Ps _lH C <br /> MAILING or STREET ADDRESS Box toinoicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> / Z Im— `0 L rO ke ❑ CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCYl0 ,1 (j'l ✓❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ` V l'� STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Clq - l� <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME cc q� CARE OF ADDRESS INFORMATION <br /> P f cc 7-r li G �� �c�S �Ic <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> �i ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 4 ZIP 7 5 O PHONE A.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS C (� <br /> CHECK ONE(t)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# AGENCYA, FACILITY ID# #of TANKS at SITE <br /> 60 / 6F9 I lololnlj� <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEN8U3 NACT#_ SUPERVISOR-DISTRICT CODE BUSINESS gN❑FFILED NO EJ �/ <br /> DT FILED <br /> [HECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> 1 <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 /> FORMA(3-2-88) <br /> 0 DATA PROCESSING COPY 0, <br />