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STATS OF.CALIFORNIT WATER RESOURCES <br /> PAYMEN :{m <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMMg. oSITE FACILITY/SITE, INFORMATION and/or PERMIT APPLI9 90 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 10' <br /> AA­WI P- <br /> 1 NEW PERMIT 3RENEWALPERMIT SCHANGEOF INFORMATIBIWELISAN-C ,�CyLOSED SITE N <br /> MARK ONLY ❑ ❑ LW" tJ AD <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CFAYRON MENTAL HEALTH DIVISION v <br /> O <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> UN AL /I S"fP"CIo1U 6413 <br /> ADDRESSJNEAREST CROSS ST IEl PARTNERSHIP ❑ STATE AGENCY <br /> ✓JCORUUTION 1-1 LOCAL-AGENCY ❑ FEDER/7��8f__ " Aw / 20 11 <br /> INDIVIDUAL ❑ OGUNIY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Tr4_,4D--Gy CA Czw9)836— o�sKr <br /> TYPE OF BUSINESS. ❑ 2DISTHIBIROR ❑ 4PROCESSOR ✓Box if INDIAN EPA <br /> �ID/# _' /A�_.,r_ #oI TANK's <br /> GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRESETYLANDS ATION o ❑ ��✓ 9 J I 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 /> FEf�IUSON ) D/_�/ �1(y21°1O1r�(`/d�3(ec-,O-b4(o PINNI;L FRANK H AREA CODE <br /> �1�n41Cr2�94-5�--16p7/�/n0 <br /> UINAME/YIG, `FIRST) PHONE If WITH�FC1WN�I f f�IVL I-115�iTDI�R93Z2 EA CODEUNT% ONE If IT/V'NAME(LAST,FIRST) PWNF, l415, I-7.7L <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUSTBE COMPLETED)w� <br /> NAME CARE OF ADDRESS INFORMATION <br /> UNION OIL CO- OF 6o4uvA0iLN IA)Oep�-,UNo <br /> MAILING or STREET ADDRESS /� ✓ xta indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 21 q� „A l A 1 1e�lI�IA g(V� (p�o CORPORATION ❑ LOCAL-AGENCv ❑ FEDERAL-AGENCY <br /> !! 141 N^✓1�" INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE_ 219459!® 4i5�'W1945—EA GDE <br /> 'I(,76 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAUNION OILS 40- of 6AU F:;0KNIA)DBD,UN CARE OF ADDRESS INFORMATION <br /> MAILING RES [COto,ndicao 13 PARTNERSHIP [I STATE-AGENCY <br /> 2- 1✓ Nosp. 4k� RPORATION FI LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME � ,a STATE 21945964iS�IT�`i "�?b�� <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOIL INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. tg III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> AP (CANT' NAMEIP INTED&SIGNATURE)40 I r DATE <br /> vsso�. cc0N5ULl'PW5r-0R-Uu0cp4_) 4 11 96 <br /> LOCAL A106NCYUiE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LHEK'10 <br /> ODE CENSUSTRACT k� SUPERVISOR-DISTRI TCODE BUSINESS PLAN FILED DATE FILED <br /> YES NO � (J -9'D <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:/- <br /> vv <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 /> DATA PROCESSING COPY <br />