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STATE OF CALIFORNIA WATER RESOURCES CONT*' BOARD " "f <br /> :. <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE Y CLOSED SITE I-J <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> O <br /> I. FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) COCO <br /> FACILITY/SITE NAlr l CARE OF ADDRESS INFORMATION <br /> VNIace �o . <br /> ADDRESS r,' / I,. NEAREST CROSS STREET <br /> il*AW ❑ PARTNERSHIP ❑ STATE AGENCY <br /> go Wy Wz be.Q pvA$(4/N/S'/Ot I�MTGN O LOCAIAGE Y ❑ FSERALAGENQ <br /> CITY NAME _TD��Ja STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CAI '2a <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑406CESSORI <br /> ✓Bo#if INDIAN EPA ID# <br /> F-11 GAS STATION F__13 FARM 5 OTHER TRUST LANDS T 10 INur ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> .L no 20 —q1 8— Z3/ $a-,ie <br /> NIGHTS: NAME(LAST, RST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME F �p � CARE OF ADDRESS INFORMATION <br /> �.L 1 <br /> MAILING o,STREET ADDRESS .52 /� xto indicate 11 PARTNERSHIP ❑ STATE-AGENCY <br /> 6® F# (NI�SI{!Nlr7aN /7L� CORPORATION 11LOCAL-AGENCY11FEDERAL-AGENCYINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE N.WITH AREA C DE <br /> L-os A-N a-ew_es GA o� 0 <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME / / 0-M _�e Cu CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESSV ,+ to indicate ❑ PARTNERSHIP 13STATE-AGENCY <br /> V r 1 U CEl LOCAL-AGENCY FIFEDERAL-AGENCY!!! ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMEe -TV STATE I ZIP CODE PHONE#,WITH AREA ODE <br /> C45, 9 s2o/ <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. ❑ II. ❑ 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 M JURISDICTION# AGENCY M FACILITY ID# #of TANKS at SITE <br /> ® = = 1 01) 15171 10 OU <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY,N-A/ME PHONE#WITH AREA CODE <br /> ( Vv N <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> /2 23/Sr <br /> \ LOCATION CODE CENSUS TRACTT## SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> VI OV /�7j() YES [:] NO EJ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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) <br /> DATA PROCESSING COPY 0 A <br />