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p x , <br /> STATE OF CALIFORI <br /> WATER RESOURCES CONTAR BOARD s`��'°'��;'l"^ <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Qy �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w ' o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `4�,.oae�P <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 C3 <br /> N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) III <br /> A <br /> FACILI SITE NAM CARE OF ADDRESS INFORMATION <br /> t S.7 1 vv1 jj Ir,-• LJ h i -4 ) Q� <br /> ADDRESS ,NEAREST CROSS STREET ✓BuIo Nale ❑ PARTNERSHIP 1:1STATE AGENCY <br /> �/� El CORPORATION ©-MCAL AGENCY ❑ FEDERAL AGENCY <br /> 1 T ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITYSTATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> 71 IDOv_\ CA g53ta <br /> TYPE OF BUS ESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR I -/Bo.if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑-S-OTRER I ESE <br /> TRUSTVATION LANDS or -_ #of TANKY <br /> ❑ 1 AT THIS SITE U <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: ME(LAST,FIRST) '209 PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �I S akcke_-V <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME T ( < CARE OF ADDRESS INFORMATION <br /> S J �V�VZ' G�'�✓� IIiJ\ 3 <br /> MAILING or STREET ADDRESS ✓box to indicate Ill PARTNERSHIP ElSTATE-AGENCY <br /> O ( a. ❑ CORPORATION 13LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME_ STATE ZI CODE PHONE#,WITH AREA CODE <br /> C� � ^ ��^ �'I ` 533 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to odicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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. ❑ it. [el, 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# #of TANKS a1 SITE SII <br /> ® 1 ooal I <br /> "� dOD <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1 <br /> `__] <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCO CENSUSTRA�� SUPERVISOR-DSTRICT rDE BUSINES,PSNFILED NG ❑ DATE FILED 1 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 1 FEE CODE RECEIPT# (I'(-'B_\JY: <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 LY. <br /> ORM A(3-2-66) . <br /> DATA PROCESSING COPY 0 <br />