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STATE OF CALIFORNIP WATER RESOURCES CONTROL'BOARD aSA <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM ="do <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS' 76 <br /> 09 LI[OR��P <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 W <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> fJ1 <br /> FACILITY ITE NAME CARE OF ADDRESS INFORMATIOy� <br /> IT � N- CG 1 j 6� <br /> ADDRES 2� ,Iy, NEARESTC OSS STREET ✓Aextoimi¢k D LOCAL AGENCY <br /> Cl STATE FEDERAGENCY <br /> AGEN <br /> O,3 `J S - SCO I S� ❑ ��OMTION ❑ LOCAL ❑ FEDERAL❑ INDIVIDUAL Cl PARTNERSHIP <br /> NAGENGY <br /> CITY NAME L STATE ZIP,CUDtd-o s SITE PHONE N.WITH AREA CODE <br /> S"I LL l� CA t��1lL <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a #of TANK's <br /> T THIS SITE <br /> ❑ i GAS STATION ❑ RESERVATION or F-1 <br /> A 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME /A -T & San \ �� CARE OF ADUR�SS INFO yMAT10 �.`,O� <br /> MAILING or STRIE-ET A1`DDR I ^ ✓BoxCO P i CORPORATION <br /> Y 1 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> P 1 O ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME STATE,.-, ZIP�ODE I � PHONE N,WITH A. I C E <br /> �Sb�-� /may_✓ 3 !u,'/��11l..1/ <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMEC r CARE OF ADDRESS INFORMATION <br /> A7 � 5D.Iti{,) i-e-_ C �c ✓Z <br /> T <br /> MAILING or STREETADDRESS {{-� %1 Box to Indicate Cl PARTNERSHIP D STATE AGENCY <br /> c1 ❑ CORPORATION ElLOCAL-AGENCYD FEDERAL-AGENCY <br /> UU v ❑ INDIVIDUAL D COUNTYAGENCY <br /> STAT ZIP CODE PHONE 0,WITH AREA CODE <br /> CITY NAME CITY /' GUI C0 2(� <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS Rfy <br /> l ll � `l <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 NAMIPRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION M AGENCY k FACILITY ID# #OI TANKS at SITE <br /> 3q l °t 3 0 OOC) <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE <br /> 1 1Tf2v Ol <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> III <br /> � 0 1 YES [-] NO E] )I <br /> O <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST#MORE TANK PERMIT FORM 'B' APPLICATION(S), UN S THIS IS A CHANGE OF SITE INFORMATION ONLY.r <br /> p FORM A(3-2-SS) <br /> 11\\V DATA PROCESSING COPY <br />