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STATE OF CALIFORNI10 WATER RESOURCES CONTROLBOARD <br /> FORM `A': °a <br /> UNDERGROUND STORAGE TANK PROGRAMAd <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I / <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE oaN a <br /> MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE b' <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) I <br /> FACT TY/SITE NAME CARE OF ADDRESS INFORMATION <br /> I s ' Q Delmar OLtoN <br /> ADDRESS NE1AR/FIST CROSS STRE T ✓gy(o intlicale ❑ PARTNERSHIP ❑ STATE AGENCY DO <br /> DO <br /> ' ✓ I n` 1 r [❑�/NOMOUp�IDN 11 LOCALAGENCY❑ COUNTYAGENC ❑ FEDEAALAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> �toC�1� Fi�� CA Jra � a ,IAT <br /> �bG -Y3sl� <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a 1,L <br /> ❑ 1 GAS STATION ❑ 3 FARM �OTHEfl TRUST LANDS ATION o ❑ / I o rue-e HofTAS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> De4mar L o (ao9931 -6175 <br /> NIGHTS: NAME(LAST FIRST) PHONE a WITH AREA CODE NIGHTS'. NAME(LAST FIRST) PHONE WITH AREA CODE <br /> So m <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e o F G <br /> MAILING or STREET ADDRESS L ✓ to indicate 11 PARTNERSHIP <br /> STATEAGENCY <br /> ITUf CORPORATION LOCALAGENCYEl FEDERAL-AGENCYJ SI 1S l �UeT Q INDIVIDUA <br /> CITU NAME COUNTY-AGENCY <br /> STATE ZIP CODE PHONE a,WITH AREA CODE <br /> os Apie -isC19 19s2 v "Ire <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r <br /> MAILING or STREET ADDRESS ✓Box to indicate 1:1PARTNERSHIP EJSTATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> 11 <br /> INDIVIDUAL ❑ COUNTYAGENC <br /> CITY NAME STATE ZIP CODE PHONE At,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. II. ❑ 111. ❑ <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 A JURISDICTION R AGENCY R FACILITY ID R #of TANKS a1 SITE <br /> o / / 6P1000 / <br /> CURRENT LOIFACILITY ;APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NNUUMPERMIT APPR A i ATE�� PERMIT EXPIRATION DATE <br /> l/O3LOCATION CBUPERVIS R-DISTRIBUSINES,PELSAN❑FIL D NO DATEFI; DCHECKk SURCHARGE AMOUNFEE CODE RECEIPT# 7 �CBYOp <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 /> RM A(3-2-88) • <br /> DATA PROCESSING COPY <br /> A _ <br />