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STATE OF CALIFORNI91 WATER RESOURCES CONTRO*OARD ;INV - l <br /> FORM `A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLIC -� r z <br /> ATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE <br /> ❑2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE SalN <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) cOD <br /> c <br /> FACILITY/ TE NAME co <br /> CARE OF ADDRESS INFORMATION <br /> QrQ on LLt )Yl <br /> ADDRESS �`�-- <br /> r NEAREST CROSS STREET ✓g NiMiple 0 PAMERSHIP ❑ SiAiE AGENLY <br /> 1 W 1 0 E . (� e r (U� Y ❑ CO�Pona70N ❑ LOCk AGENCY ❑ FeoER i acEN <br /> CITY NAME 0 so,N AL ❑ CWN1Y-AGENCY <br /> CT 1 1 STATE Zle CODE SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE Of BUSINESS. ❑2 DISTRIBUTOR ❑4 PROCESSOR '/81 If INDIAN EPA ID # (`Jl <br /> ❑ 1GAS STATION ❑3FAgM $OTHER RESERVATION or ❑ Not TANK's <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCYCONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST FIRST) <br /> It vu PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) <br /> ✓� PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> ENAMEO L-`� CARE Of ADDRESS INFORMATION <br /> W DRESS cl <br /> Boxtontlicale ❑ PARTNERSHIPJUKEN <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ STATE-FEDERAFEDERALO-�AGECy <br /> NCVENCY <br /> ///��� ❑ INDIVIDUAL 0 COUNTY-AGENCY/,� _ n STATS ZIP CODE PHONE#,WITH AREA CODE <br /> 1 ` CJ_E _ -- /Lf1•_L y c( i S. t s u s a s I <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME c '� �_� ^ <br /> J�#L_cn ^ CARE OF ADDRESS INFORMATION <br /> W'J <br /> MAILING or STREET ADDRESS ✓Box to lntlicale Cl PARTNERSHIP <br /> ❑ CORPORATION 0 LOCAL- 0 STATE-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY- GENCY ❑ FEDERAL-AGENCY <br /> CITY NAME <br /> 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. ❑ 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 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# FACILITY ID N <br /> 3 � � If/l 01 TANKS at SITE <br /> V I l I T1 <br /> O <br /> CURRENT LOCAL AGENCY ACILITY ID N APPROVED BY NAME <br /> R /1 r ((v PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION GATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> Q A '13 /)') I/y DATE FILED <br /> 1 1 O�JOu `-'( YES Ej NO 0 I a. <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPT# BY: <br /> ` THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />