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STATE OF CALIFORNI.0 WATER RESOURCES CONTROROARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY o4' I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS TE <br /> ONE ITEM 511h INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NCAPE OF ADDRESS INFORMATION <br /> f}I �AME Q VI C ec, <br /> ADDRESS 0 NEAREST CROSS STREET 611 ❑ PARTNERSHIP ❑ STATE AGENCY <br /> Om <br /> 15-1"ter GOAPORATION ❑ LOCALAGEND ❑ FEDERALAGENCY <br /> Q L 1 ❑ MDIVIDUAL ❑ COJN Y AGENCY .� <br /> CITU NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE CD <br /> S ce CA 5A a 9 ( v9 - yea l <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID 4 <br /> ❑ 1 GAS STATION ❑ 3 FARM Lj 5 OTHER RESERTRUST YLANDS ATION dl ❑ W TL-Ci AT THIS SITE ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> FrV{1c hcaraiech -ner `/ ' S4, X63 <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS NAJE(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> -S <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME _ CARE OF ADDRESSINFORMATION <br /> W checcrSory <br /> MAILING or STREET ADDRESS :53 ✓$ox to odicale ❑ PARTNERSHIP ClSTATE-AGENCY <br /> v L�CORPORATION LOCALAGENCY11 FEDERAL-AGENCY Q ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> aC,ravn o c1q 19 "5- ?/ .7 cy1i� <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,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. ❑ it. ® 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 If AGENCY# FACILITY ID# IF of TANKS at SITE <br /> 3 D 10 1 / E = a1010101 / 1 <br /> CURRENT LO AGENCY FACILITY ID Y N <br /> # APPROV D AME PHONE#WITH AREA CODE <br /> /f I nO '�� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 711-51 F0 <br /> LOCATION CODE CENSUS TRACT N UPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED `-('�� <br /> © ' �L3, �� YES NO � / f V " <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p Y <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 INFORIIIATION ONLY. <br /> FORM A(3-2-88) • 0 <br /> DATA PROCESSING COPY <br />