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STATE OF CALIFOR <br /> WATER RESOURCES CONT BOARD <br /> s.' <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM = � � Ao <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 18 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION l _Kr 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) u <br /> FACILITY/SITE NAME CARE R� OF ADDRESS INFORMATION <br /> A1Z I3 CLL-PL45LLC 0&`R9S ry <br /> ADDRESS NEAREST CROSS STREET ✓8or to indmele •��1 PARTNERSHIP ❑ STATE AGENCY <br /> 1 �j ❑ CORPORATION LOCAL AGENCY ❑ FEDERAL lel J vl If�J �-TT�N ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> SIC)c.&Te1J CA eNE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR d PROCESSOR ✓Box if INDIAN EPA ID It <br /> RESERVATION orA I ' 1 #of TANK'# <br /> ❑ 1 GAS STATION ❑ 3FARM 50THER TRUST LANDS ❑ Iv�N� AT THIS SITE Z <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAV NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �Lcl-�vL_ ALT 20� 4 -82� <br /> NIGHTS'. NAME(LASTFIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAJr'E CAR OF ADDRESS INFORMATI <br /> o Ul FlLt�2 . �lcttyL5 <br /> MAI INC or STREET ADDRESS ✓Box to indicate ❑ PP TNERSHIP ❑ STATE-AGENCY <br /> /,1� A..� ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITU STATE ZIP CODE HONE WITH AREA CODE <br /> (� 95 r8 Z <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> N ME1 �� RE OF ADDRESS INFORM TION <br /> (LL Oro -�UPj1LC_W 5 o . NLcftL <br /> M LING ar <br /> STREET ADORE/ ✓Box to indicate ❑YATETNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE ONE WITH AREA CODE <br /> 5'2-0 7, 4 92 <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. ❑ II. Ill. ❑ <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 It AGENCY# F CILITY ID 1 It of TANKS at SITE <br /> 3q � X33 � z <br /> CURRENT LOCAL AGENCY FACILITY ID M AP VED BY NAME PH E#WITH AREA CODE <br /> PERMIT NUMBER I PERMIT APPROVAL DATE PER MI <br /> LOCATION CODE CEE7NSUS TFQAACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3li (T20 YES NO � <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE ASCIIPTM 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 /> \ <br /> F FM A(3-2-88) , <br /> N\\ '.� DATA PROCESSING COPY -a <br />