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STATE OF CALIFORNIAO WATER RESOURCES CONTROROARD <br /> FORMA": UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT n 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE lL <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAMEJ0 h,rl H d I u1 PXd.Q- <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS syn NEAREST CROSS STREET ✓owwwayw ElPAETNEFSNIP El9ATE AGENCY <br /> 1 I I S• Vr 11 NCrEDXEl pN ❑ FOCA�A-GBI ElRGEAALAGENC <br /> CY <br /> CITY NAMEK U' STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ p TRIBUTOR F-] 4 PROCESSOR -/Box if INDIAN EPA IT`D.•Al <br /> RESERVATION or N of TANK's q <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE V/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) T 1_ ,,, PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Ho/u) J YNL <br /> NIGHTS: NAME(LAST,FIR I PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> John. HOlwmitst <br /> MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 2O n J / y�/T �• ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> w <br /> ✓o ecL evlocxf y✓ 11INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE P ONE N,WITH AREA CODE <br /> lu o ml y-95�9 6/6 5"a/- a�7s� <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME ✓e <br /> s G.,'tae CARE OF ADDRESS INFORMATION <br /> CGS Ccl�d <br /> MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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 N �JURISDICTION N 1 AGENCY# I FACILITY ID K M of TANKS at SITE " <br /> D d I l 8 (n c <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> I�t[�N�N 11 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED G <br /> YES NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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) 10 0 <br />