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STATE OF CALIFORN& WATER RESOURCES CONTRAOARD <br /> . s <br /> FORM A,: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE ' R, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-] I NEW PERMIT ❑ 3 RENEWAL PERMIT �6 CHANGE OF INFORMATION ❑ 7 PER OSED SITE f'a' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE rV <br /> 4 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) W <br /> FACILI ITE ME r CARE OF AADRESS INFORMATION <br /> ADDRES �y/ .r/ C NSA E{7 ST CgpSS STREET ✓Br.to in,11.11 ❑ PARTNERSHIP STATE AGENCY <br /> 1 S ` y � (K�—(f"^� / CORPORATION ❑ LOCMAGENCY FEDERALGAGENCY <br /> ❑ INDWIIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE ITE PH NE K WITH AREA CODE <br /> t'/,l CA �Lo �q _T. �3 <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA NO ft <br /> El GAS STATION ❑ 3 FARM OTHER TRUST LANDS ATIO o ❑ :N/TA AT THAS SITE a�' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D YS: NAME(LAST,FI ST PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) P ONE#WITH AREA CODE <br /> /I uLW.i 5 `ld -7 Y'96, S A� d <br /> NIGHTS. NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHT - NAME(LAST,FIRST) P ONE#WITH AREA CODE <br /> S A Zl � � s <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM 1 CARE O ADDRESS INFORMATION <br /> AJ A <br /> MAILING T EET ADDR SS 1 ✓80x tomoate ❑ PARTNERSHIP STATEAGENCYZ® �I S / r ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAM STATE ZIP CODE PHON #,WITH AREA CODE <br /> cyt UTI 7110—N6,6, <br /> 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STROEYADDRESS ✓Dox tro oocaG, ❑ PARTNERSHIP El STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.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: 1. 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 /> COUNTY R JURISDICTION N �AGENCYmR FACILITY ID k N of TANKS at SITE <br /> Ora / 3 6 D D <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY AME PHONE M WITH AREA CODE <br /> c_- 2 K LIG / z ® 4 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS iR N SUPERVIS R-DISTRICT CODE BUSINESS PUNFILED / DATE FILE <br /> ZJj Z5 O NOr/LJ�( µh If Z.D <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <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 A(3-2-88) <br /> DATA PROCESSING COPY <br />