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STATE OF CALIFOR --�' <br /> WATER RESOURCES CONOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> z <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT ED 517E F� <br /> ONE ITEM ❑p INTERIM PERMIT ❑ # AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S�'; _-4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) (7) <br /> FACILITY/SITE NAME <br /> CPRE OF ADDRESS INFORMATION // <br /> �- OLlI <br /> ADDRESS — NEAREST CRO STREET ✓Rom <br /> I111101e LJPARTNERSHIP ❑ STATE AGENCY <br /> - L ❑ TYR 13LOGALAGENCY ClFEDERALAGBICY <br /> '� W ❑ COUNiKA6ENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE q,WITH AREA CODE <br /> CA gss3L� Coot' - 8 T <br /> TYPE OF BUSINESS'. DISTRIBUTOR 4 PROCESSOR ✓Bax if INDIAN EPA ID # <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION or #of TANK's <br /> TRUSTLANDS ❑ 1 _ 00 c2 / (O .7 3 73 AT THIASITED <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME QRST,FIRST) PHONEomoi# c. nn Lam- / ' nNIGHTS'. NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE <br /> AA /# <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME leo <br /> " CARE OF ADDRESS INFORMATION <br /> /`O !-L AN-1 /eCd t_l tl k ez- 0" /;^A <br /> MAILING or STREET ADDRESS V ✓Box -tllcaLe ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 3 u / ��� ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> N� INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> �sc�1 �o c a 9s3 aL� Lace 8 s -� s� <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r�rr c { ,L C s /A 0- <br /> MAILING orSTREET ADDREs ✓Box tlicaie ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> .S/A 71r— ❑ RPORATION ❑ LOCAL-AGENCY Cl FEDERALAGENCYINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> s/ g -S/A S/h S/4 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR DOTH 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# AGENCY# FACILITY ID At of TANKS at SITE <br /> 2CURR3 °1 o 1 (91 2 3 f 7-2- <br /> CURRENT <br /> ENT LOCALAG CY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> U2 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TR # SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED (� <br /> C!J�E Z ) YES NO <br /> CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> FORMA(3-2-63) <br /> DATA PROCESSING COPY a J <br />