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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> W. <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE _ <br /> C\.LiOPN\P I'i L.' <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO D SITE N <br /> ONE ITEM Ej p INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N <br /> FACT /SITE NAME�II/UN CC <br /> y- CARE OF ADDRESS INFORMATION <br /> 1CD. <br /> ADDRESS �j.1�� /��.-fin NEAREST CROSS/STREEETT�{ ✓ 0IId.11 ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 1 3 2 O A/, • • �'"' \ � [N / LP CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> ❑ <br /> CITY NAME IINDIVIDUALElCOUNTYAGENCY <br /> STATZ�Pf5k WITH <br /> ENE AREA CODE CA 03 Vii.8—/z3 <br /> TYPE OF BUSINESS: 0 2 DISTRIBUTOR 4 ESSOR ✓Bo%i(INDIAN EPA 10 # <br /> I GAS STATION 3 FARM 5 OTHER TRUSREBERESERVLANOS ATION or ❑ #of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> OZH��A CODE RAYS: NAME <br /> S: KeL FIRST) �&� HONE pIW J�AST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE C#s/WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAMEUA//OA/ CARE OF ADDRESS INFORMATION <br /> MA0r5g gDSS /�lNLnhJ 7a� Zvrn x to indicate PARTNERSHIP STATE AGENCY <br /> OETION LOCAL G <br /> ❑ FEDERAL-AGENCY <br /> A <br /> ❑ N ❑ <br /> CITY NAME STATE ZIP CODE HONE p.WITH AREA CODE <br /> Lis rA 00 q0 2/3 '7zq-9SS-b <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> LIA1/61V _T&C 60. <br /> - CARE OF ADDRESS INFORMATION <br /> STREET MAILI , ADO 55 v C' ✓Box to indicate 11PARTNERSHIP Cl STATE-AGENCY <br /> xOn !OS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / <br /> CITY NAME ! El INDIVIDUAL ElCOUNTY-AGENCY <br /> S7KfioN ST? <br /> As2D/ PHONg W�y9o% 3/ <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS Y// !/ <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. 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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> D 6 23 5 <br /> CURRENT LOC AGENCY FACIL TY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> (AVON 13 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED <br /> b� 23 ' 90 3211 YES NO � <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> BY: <br /> YywSi <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIFORM A IS 2 88) ON(S), US THIS IS A CHANGE OF SITE INFORMATION ONLY. t <br /> v v\ \ DATA PROCESSING COPY <br />