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OF <br /> STATE OF CALIFORNIA• WATER RESOURCES CONTROL OARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM z <br /> _. <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m o ;P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ ' W PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El ENTLY CLOSED SITE F'J <br /> ONE ITEM 22 INTERIM PERMIT E14 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I-► <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> �► � �ih/e P�R � <br /> NEAREST CRO STREET WTIZEEl ORPMTION LMANGNU ❑ FEDERAL-AG NNG�YOT <br /> ADDRESS CY 3bA 14;IV <br /> S ,N["_\. <br /> ❑ INDIVIWAI ❑ CAUNtV-AGNCV <br /> CITY NAME / STATE <br /> ZIP CODE SITE SITE PHON�WITH q 9Y3 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID a C`J #of7TTA`NIKK's ' <br /> 1 GAS STATION 3 FARM RESERVATION or AT THIS SITE <br /> 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE It A C <br /> WITH AREODE DAYS'. NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIR?L) PHONE If WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> sll�n2 �'Cl�w-: <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME V _�`IelGe TO / CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRE S ✓Box to intlicale ❑ RTNERSHIP ❑ STATE-AGENCY <br /> `/ ❑ CORPORATION LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 2J N FL AOMO O ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITU NAME 4-7QGA-7D� STATE� ZIP CODE 0� PH'ONE�—ITH AREA CODO f�� <br /> 111. TANK OWNER INFORMATION &ADD SS (MUST BE.COMPLETED) (-t/ yl Z <br /> NAME G, A E OF ADDRESS INFORMATION <br /> we <br /> MAILING or STREET ADDRESS ✓Bax to,nftrite El PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> 'L o ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> S - STATE ZIP CODE�� PHONE N.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: 1. El 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS 81 SITE <br /> po / zy6 ao o / <br /> CURRENT LOCAL AGENCY FACILITY 14N <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> /Cg1/O/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> Z Z8 f� <br /> LOCATION CODE CENSUS TRACT# SUPERVISO -DISTRICT CODE BUSINESS PLAN FILED EL4 <br /> 2 (Dy !7L VES E] NO <br /> CHECKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM <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 INFORMATIO <br /> FORM A(3-2-88) • <br /> DATA PROCESSING COPY <br />