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STATE OF CALIFORNIA * WATER RESOURCES CONTROLwRD �� U; <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM I _"4i d <br /> � <br /> SITE /j FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> X C�li.OaN,� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITTE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITYISITE NAME <br /> G 175 12612620STATE AGEKV <br /> Sc <br /> ADONESS NEAREST CROSS STREET ❑✓Nw ❑ LOGAI El MIMMDIcr <br /> 7 C S P m ! ❑ VM'DIYl ❑ fdU(IY-.ILDlLY <br /> STATE ZIP CODE SITE PHONE 11.WITH AREA CODE <br /> CITY NAME CA <br /> �n�2GQ ILw <br /> ttPE OF 6USINESS. ❑2 DISTRIBUTOR ❑ /PROCESSOR EPA D'RESERVATION or AT THI0 of S <br /> F—] I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE N WITH AREA CODE <br /> DAYS. NAME(LAST.FIRST)) <br /> PHONE N WITH AREA CODE DAYS'. NAME RAST,FIRST) <br /> NIGHTS. NAME(LAST,FIRST) <br /> PHONE It WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> If /ea,.e L c <br /> ✓Box w 6 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING a STREET ADDRESS <br /> ❑ CORPORATIRATION ❑ LOCALAGENCY 13 FEDERAL-AGENCY j <br /> j ` } �,/C •� Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> D V STATE ZIP CODE PHONE N.WITH AREA LADE <br /> CITY NAME <br /> 111. TANK OWNER INFORMATION III: ADDRESS — (MUST BE COMPLETED) <br /> GRE OF ADDRESS INFORMATION[NAMEGmNG m STREET ADDRESS ENCY <br /> ✓Boa to RATIIO ❑ PARTNERSHIP ❑ FEDESTATRA AGEN❑ NDIIVIDUAl 0 COUNttAGENCY ❑ FEDERALAGENGY <br /> $TATE ZIP CODENAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(T)SOK INDICATING WHICH ASOVS ADDIISSS SHOULD SE USED FOR SO7M LEGAL NOTIFICATION AND BILLING: L El IL ❑ IU.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'$NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FACILITY ID S B of TANKS Al SITE <br /> COUNTY11 JURISDICTION AGE�� <br /> 3 � oEa � i � D � c L <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> APPROVED BY NAME PNONL 1 WfT I AREA CODE <br /> y �? - 6 5PERMIT EXPIRATION DATE <br /> PERMIT NUMBER PlRYIT APPROVAL DAT! <br /> _ BUSINESS PLAN FIND DAT[PILED <br /> LOCATION <br /> �CODe CENSUS TRACT SUPERVISOR-DISTRICT CODE YES ❑ NO ❑ <br /> _ c✓ ' 3.f0 3 -2 BY: ltd <br /> FEE CODE RECEIPT F C, <br /> CHECK F PERMIT AMOUNT WRCNAIIO!AMOUNT / <br /> THIS FURY MUST BE ACCOMPANIED SY AT LEAST(1)OR MORE TANK PE FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION OMLT\ LdV <br /> YVHM A 13-L Wll <br />