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V 1� 6J <br /> STATE OF CALIFORN WATER RESOURCES CONTRIPBOA <br /> FORM 'A': "^ <br /> UNDERGROUND STORAGE TANK PROGRAM (_ 1 - ' io <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLI fAF'MANTA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE F ERMIIT/$ER <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I <br /> FACILITY/SITE CARE OF ADDRESS INFORMATION <br /> ADDUcRES_ NEAREST CROSS STREET ✓ Ali ❑ PARTNERSHIP ❑ STATE AGENCY DO <br /> •T �,yUG CL` PORATION EDLOCALAGENLY EDFEDERALIGENCY <br /> L �T INDIVIDUAL ED COUNTY AGENCY <br /> CITYAME STATE ZIP CQQF SITE PHONE#,WITH AREA CODE V#1 <br /> CA � �� �� 6 <br /> TYPE OF BUSINESS O <br /> ❑ 2 DISTRIBUTOR ❑ q PROCESSOR ✓Box if INDIAN EPA ID # <br /> R RESERVATION or ����,pp #o1 TANK's <br /> 1 GAS STATION 3FAflM <br /> ❑ ❑ TRUST LANDS ❑ /u`� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) A PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE kWITH AREA CODE <br /> NIGHTS: NAME(LAST FIRST) PHONE q WITH AREA CODENIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ✓1/ 6 11 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> f CARE OF ADDRESS INFORMATION <br /> 330,MAILIN or STREET ADDRESS �Py� (''qL /� �/��✓YSON to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> � — ^� vD✓ LJ IN "DUALION ED LOCAL-AGENCY 11❑ COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE Q.. ZIP CODE PEON p,WITCH AREA CODE <br /> Ill. TANK OWNER INFORMIATIOliti ADDRESS— (MUST BE COMPLETED) <br /> NAME �-e 1 CARE OF ADDRESS INFORMATION <br /> ,L 6e� r'� evil LJ 6G. <br /> MAILING or <br /> STREET�ADDRESS ✓ ox to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY3�S IN - O G �� CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME � INDIVIDUAL ❑ COUNTY-AGENCY <br /> XXE5 Al 100i STATE ZIP CORE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> _c NECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATU ) DATE <br /> "rK�, S� 1- M,ki- Glace <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# IF of TANKS at SITE <br /> O 10 1 / d I C> 624 <br /> CURRENT LOCAL AGENCY FACILITY ID# "' <br /> 09 APPROVED BY NAME PHONE#WITH AREA CODE <br /> S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT## SUPERVISO -DISTRICT CODE BUSINESS PLAN FILED DATE FILED r/ <br /> 1 YES E] NO 7,7901X <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: IIY// <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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY 'I <br />