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�w <br /> STATE OF CALIFORNII WATER RESOURCES CONTROIARD <br /> a - �a <br /> `►e m <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM io <br /> SIT � .; <br /> FACILITYISITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMAN Y CLOSED SITE N <br /> ONE ITEM � 2 INTERIM PERMIT 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE Q0 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C7 <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME <br /> GQ !f for ► i - due <br /> NEAREST CROSS STREET xloindicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ADDRESS RPORATIQN 11 [I FEDERAL-AGENC <br /> S 1 rW ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE _ SITE PHQ NE#,WITH AREA CODE <br /> CITY NAME � J G / _ ! CA L 0 �'1 Q [ Jam"C!' <br /> TY71GASSTATION� <br /> USINESS �l –1 Z DISTRIBUTOR��4 PROCESSOR ✓Box R INDIAN EPA ID # #01 TANK's <br /> RESERVATION or AT THIS SITE <br /> 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) El EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE#WITH AREA CODE DAYS' NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> DAYS'. NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME{LAST,FIfl T} PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> �0 r J' r_ <br /> MAILING or STREET AO ESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> r STATE ZIP COpE PHON/E1#.WITH AREA CODE <br /> CITY NAME G e/� A j �} p� v <br /> I11. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME d&Y-,+ <br /> 1! LL- ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGFNCY <br /> - � 6vcc ❑ INDIVIDUAL ❑ COUNTY-AGENCY(/�'{�ONE C� /� <br /> CITY NAME <br /> �STEATE ZIP CODE 0 1V"nWITH{A&YI— l 1 <br /> ti 5 iJ <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: <br /> THIS FOPM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE} <br /> LOCAL AGENCY USE ONLY <br /> Fu _ <br /> JURISDICTION# AGENCY# <br /> FACILITY ID# #of TANKS at SITE <br /> I L—L—L-1 <br /> GENCY FACILITY ID K <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> e _�D- <br /> [PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CATION CODE CfURAC SUPE OR DI8TRICT CODE BU81NES3 PLAN FILED <br /> *BY: <br /> � LO <br /> 01 CA ? , <br /> (��(] YES NO �ECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPT N <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 /> FORMA(3-2-86) <br /> DATA PROCESSING COPY � /` <br />