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STATE OF CALIFORNIA WATER RESOURCES CONTROBOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM A,o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , <br /> COMPLETE THIS FORM FOR EA2 FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E�KPERMANENTLY CLOSED SITE FJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> (n <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) OD <br /> FACILITY/SITE NAME CARE OF ADO R SS INFORMATION A <br /> oc_k o,v a kous-e- reel, /en/ <br /> ADDRESS NEAREST CROSS STREET <br /> S E rdida 11 PARTNERSHIP 11 STATE AGENCY <br /> V � RPORATIO11 LOCLAGENCY 11 TEOERALAGENC <br /> Y� f <br /> Cl INDIVIDU ❑ COUNT(AGENC( <br /> CITY NAME STATE ZIP CODE SITE PHONE JI,WITH AREA CODE <br /> S oc or4 CA gs�o3 2 -962-zg6p <br /> TYPE OF BUSINESS. E] 2 DISTRIBUTOR ❑ a <br /> 4 ROCESSOR Box if INDIAN EPA ID <br /> ❑ 1 GAS STATION ❑ 3 FARM �THER RESETRUSRVLA ION or ❑ It of TA SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FAST PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> M \Oo z - -1,53- 10 Z -WS-010 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> jqr <br /> MAILING or STREET ADDRESS <br /> I/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ` El CORPORATION CILOCAL-AGENCY 1:1 FEDERAL-AGENCY <br /> S (/D ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> ^'- 110e 6W Z4M .2/3- 697- S23.2— <br /> Ill. <br /> 232III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r <br /> MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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. ❑ if. ❑ 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 If AGENCYA, FACILITY ID A If o/TANKS at SITE <br /> 3 9 d -1 li IDO D <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> k _5093 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0 '12 3, dd YES NO E] 5 �7 <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: O <br /> THIS FORM MUST BE ACCOMPANIEDBY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-58) • DATA PROCESSING COPY& <br />