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STATE OF CALIFORNIA WATER RESOURCES CONTROL PARD <br /> FORM `A': �sA <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> S FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;oil l <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITEfoaN�P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PER TLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Die- ttg� ab h e <br /> ADDRESS N AREST CROSS STREET ✓BoemlMirale ❑ PARTNENSHIP ❑ STATE AGENCY N <br /> ❑ CORPORATION ❑ LOGAL-AGENCY ❑ FEOEAAbPGENCY I"a <br /> e e e e hC 2 Dr• ❑ wolmouAL ❑ coUNTY GEN w/� <br /> CITY NAME STATE ZI CODE SITE PHONE 4 WITH AREA CODE <br /> Sfoc Yo, .� CA g5Q05 aoR <br /> TYPE OF BUSINESS'. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM �THER TRUSTVLANDS ATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> iW2aovqyp-0511 <br /> NIGHTS'. NAME(LAST,FIRS ONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Scam e- <br /> ao 457 -I 8oP <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> V <br /> MAILING or STREET ADDRESS ✓Box to'mdicate ❑ PARTNERSHIP ❑ STATEAGENCYq tee <br /> PORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> ll�� ItR'INDIVIOUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE W,WITH AREA CODE <br /> S-16 �v> CA O_5 dao `13/ '30 F3 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 0 61)119A=2 <br /> MAILING or STREET ADDRESSv ✓Box to iod,cale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITU 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. Xif. ❑ 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 /> 11 <br /> 6 / T 3 �f Q 1010 / <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEN TjiACO SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED NO DATE FILyED Q' <br /> / �:f( YES / O <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# IF I 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(3d-88) <br /> DATA PROCESSING COPY cJ <br />