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rNQ <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> SEP.��441 l�f <br /> FORM `A': e <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION_ 2 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑15 CHANGE OF INFORMATION 7 P NEN. Y OSED SITE IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ^ <br /> r <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) C <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> DILA Co - <br /> ADDRESS <br /> ^�f W/*' e/��0 O NEAREST GROSS STREET ✓Bw Whil k 0 PARTNERSHIP 0 STATE-AGENCY <br /> 11 LOCAL AGENCY <br /> Z_% ;v _1, v �" 13 IO NR IO�UAL� ❑ CAUNIY-AGE C 13 FEGEHAI-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> SZa411�-Tv 14 CA a 517,49 <br /> TYPE OF SINESS: ❑2 DISTRIBUTOR 4 PROCESSOR -/Box if INDIAN RESERVATION Of EPA ID k <br /> q of TANK'e <br /> I GAB STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ 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 /> 1 RE�°l1 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Gam$ G/ <br /> '0 <br /> 4V( O <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> /� ( 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> '� I"XJ �O IX�V rV�9� 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> � Ei.FA.I/vA� �v- DA-VI .SIJ <br /> MAILING or STREET ADDRESS p ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ./ley (�!1 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Q <br /> L� /` ✓b 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 6 LA a 1 a303-z <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. ❑ Ill. <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 N #of TANKS at SITE <br /> 0 161 t 17 1 �; k I I 1 1 131_ <br /> CURRENT LOCAL A,7CY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> W <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR"DISTRICT CODE BUSINESSPL NO <br /> PLAN FILED ❑ DATE/ILFD <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7 MORE TANK PERMIT FORM 'B'APPLICATION(S), UNIL IS IS A CHANGE OF SITE INFORMATION ONLY. �v <br /> FORM A(3\-88) <br /> \ •'17'jJ�\ �`// DATA PROCESSING COPY <br />