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STATE OF CALIFORNIt WATER RESOURCES CONTRO•BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I o <br /> COMPLETE THIS FORM FOR EACH ACILITYISbE `'�noayN <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑2I INTERIM PERMIT ❑ 4 AMENDED PERMIT E:]6 TEMPORARY SITE CLOSURE o N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Cr) <br /> F+ <br /> FACILITY/SITE NAME � CARE OF ADDRESS INFORMATION <br /> E l e ,* S <br /> AD p SS , - •, NEAREST CROSS STREET ✓g¢rp 0 MAL-Aayp (] FSTATE EXIlNAGEy <br /> !/r�11J (////J TON O U1f"AGE,Y 0 RDEfubeGEluLY <br /> ❑ CONN#C,fNLY <br /> CITY NAME STATE ZIP CODE TE PHONE N,WITH AREA CODE <br /> a k--'9 o s <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓RESBox it INDIAN EPA ID p <br /> ❑ I GAB STATION ❑3 FARM Ei 'r ER TRUSTY' of ❑ Fo1TANK'N <br /> AT TNIS SITE ' <br /> ATION <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S Tcis; knyr-4305 <br /> 5 <br /> NIGHTS: NAME(LAST,FOIST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Sa rr. 09 S► 3 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME oerRede ('^ <br /> CARE OF ADDRESS INFORMATION <br /> t <br /> MAILING or STREET REQ s,� i31 v m0A O 0 PARTNERSHIP 0 STATE-AGENCY <br /> 7 0 PORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> NDIVIDUAL ElCOUNTY-AGENCY <br /> CITY NAME STAj€� ZIP CODE PVIO;V 6A4X,WITH AREA+ODE7, <br /> Ill. TANK OWNER INFOR ATION ADDRESS—(MUST BECOMPLETED) CTC �r(� <br /> NAME CARE OF ADDRESS INFORMATION <br /> as o e <br /> MAILING or STREET ADDRESS ✓Box to iWicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ 11. ❑ 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 S JURISDICTION 0 AGENCY N FACILITY ID N� N o/TANKS at SITE <br /> O O / 13101 S I 0 0 / <br /> CURRENT LOCAL FACILITY AGENCY Y ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> . n a Ll <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> G sal 3 <br /> LOCATIOJN CODE CENSUS TRRRACTIpLy� SUP VISOR-DISTRICT CODE BUSINESS N FILEDDATE FI D Wei <br /> (y <br /> J <br /> 3, a(J YES E] NO [I �/ '� / 6 0 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N Y; <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 />