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STATE OF CALIFORNIP WATER RESOURCES CONTROL CARD <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAMa <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION f <br /> 09l,f OPi�P <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE - <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 215 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE w <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 67 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) co <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> LF04 �;CCUDO S ,���,y�"^',.������� <br /> ADDRESS + NEAREST GROSS STREET Lf e 0 PARINERSHIP 0 STATE AGENCY <br /> l V L) '' 1 `�,\ fAAPOAATION 0 LOCAL AGENCY 0 FEOEAAL AGENCY <br /> W `/ 0 INDIVIDUAL 0 GJUNiKnGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> 2 mclv CA c53 - Ff3 -- 3oc� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTO ❑ 4 PROC R ✓Box it INDIAN EPA ID # #of TANK'# <br /> RESERVATION or ❑ ./� AT THIS SITE �-- <br /> ❑ 1 GAS STATION ❑ 3 EARM OTHER TRUST LANDS F 1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME VAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> PeAr [.vim ^`Fn UP S c�-2,r✓- <br /> 83S Oho <br /> NIGHTS: NAME(LAST F ST) PHUNE N WITH AREA CODE NIGHTS. NAME(LASTFIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME f� CARE OF ADDRESS INFORMATION <br /> ucc <br /> MAILING or STREET ADDRESS ✓Bo intlicale 0 PARTNERSHIP Cl STATE-AGENCY <br /> ORPORATION GLOCAL-AGENCY GFEDERAL-AGENCY <br /> COAL' CAL INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE Z`C,( PHONE# WITH AREA CODE <br /> G vYl 1 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> El CORPORATION GLOCAL-AGENCY ElFEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. II. ❑ 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# /#of TANKS at SITE <br /> U v I c) 10 a- <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Rfl I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINES1P S <br /> CHECK N FILED NO -3 DATE FILED —O(_O/ <br /> l PERMIT SURCHARGE FE <br /> MOUNT E 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 /> / FORM A(3-2-88) <br /> W/ Is DATA PROCESSING COPY <br />