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STATE OF CALIFORNM WATER RESOURCES CONTR OARD !z` <br /> �.or- <br /> .. ,, <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM ° <br /> SITE F CILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' S <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 ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE y <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L)GK1 NCr N <br /> ADDRESS NEAREST CROSS STREET <br /> I/IS,to PJI 0 PARTNERSHIP 0 STATEAGENCY Cn� <br /> j `/ 0 CORPORATION 0 LOCAL AGENCY 1yFEDERAL-AGENCY <br /> E Tt 1 I u,-- 74 <br /> O I,1 7 111:3INDIVIDHAL COUNTY AGENCY,/ c <br /> CITY NAME STATE ZIP CODE ITE PHONE#,WITH AREA CODE A' <br /> tSj CA 01520 20q — Z(cg <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESE❑ I GAS STATION ❑ 3 FARM o OTHER TRUSTVLANDS ATION a ❑ I AT THIS SITE <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> GI uA Es �4 - 2 ' S /t <br /> NIGHTS'. NAME(LAST FI ( 't ST) PHONE#WITHAREA COO E NIGHTS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> 5 (zoq) -`3FS3 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> L L C Cr J M& LLL <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE AGENCY <br /> ^x ^ 0 CORPORATION ❑ LOCALAGENCY ❑ F D RALAGENCY <br /> O• `+'ALJ ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAMESTATEf� ZIP CODE PHONE#,WITH AREEAA CODE <br /> l ! ZJ — Z�0 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box I.odicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ II. ryr 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# AGENCY# FACILITY ID# If of TANKS at SITE <br /> ol <br /> CURB NT LOCAL AGENC3Y FACILITY ID# APP 0 D BY NAME PHONE#WITH AREA CODE <br /> PERIAIT NUMBER PERMIT IPPROly.,DATE PERMIT EXPIRATION DATE <br /> 31-7-199 <br /> LOCATION CODE CENnSUS TRACTM SUPERVISOR-D TRICT CODE BUSINESS PLAN FILED D�(AT ILE <br /> d FSO YES NO V <br /> CHECK# PERMIT AMOUNT SURCHARG AMOUNT FEE CODE RECEIPT# BY; <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) ` `) <br /> �� DATA PROCESSING COPY 7' <br />