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STATE OF CALIFORNR WATER RESOURCES CONTRIIBOARD r-oF <br /> i Zeas ..rNf. <br /> w w <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM 'moo z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑❑ 1 NEW PERMIT F—] 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERAI�ANENTq CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE (( 14.0 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) (J0 <br /> FAC TV/SITE NAME CARE DRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ edrale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> A /y '�/J� �APRO",ON ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> /✓ /!'L •Jy��l Q ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE DECODE SITE PHO E p,WITH AREA CODE <br /> Gd4l CA S� �!D 20� 36s Z'F <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROQESSOR -/Box it INDIAN EPA ID IT 9OI TANK's <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION or AT THIS SITE '0 0 <br /> ❑ TRUST LANDS El <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) HONE N WITH AREA CODE DAYS' NAME(LAST,FIRST) PHlO�N WITH AREA CODE <br /> 0 3 0_? �f7 �'4 SIA <br /> NIGHTS: NAME(LAST,FIRST) CPHONE N WITH AREA CODE NIGa NAME(LAST,FIRST) PHON N WITH AREA CODE <br /> ZDj 3�8`j681 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CAREOF ODRESS INFORMATION <br /> 3/A ,vim <br /> MAILING or STREEyT7ADDRESS ✓9o,Cio indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> U. /� ( / � CORPORAT❑ INDIVIDUALION 0 LOCAL-AGENCY❑ COUNTY AGENCY ❑ FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE <br /> 'OFA DRESS INFORMATION <br /> 5 1A A,/ A <br /> MAILING or STREET ADD ESS ✓B&to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ff CORPORATION ClLOCAL-AGENCY 11FEDERAL-AGENCY;7 <br /> (' 1 3 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CO E; / PHONE R.WITH AREA CODE <br /> L L/—'f f J( Z.O t 36 - V 7 <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. ❑ it. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N a of TANKS at SITE <br /> = = = 10 10 12 Z o v 1 a <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAJE PHONE IT WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DAPERMIT EXPIRATION DATE <br /> Z-0&19 <br /> LOCATION CODE CENSUS TRAC�T{O, SUPERVISOR-DISTRICT <br /> �CO E BUSINESS PLAN FILED ATE FILED / <br /> IcI/ L ,3V �7OC� YES E] NO f I� �(� <br /> HECKX PERMIT AMOUNT SURCAkRGd AMOUNT FEE CODE RECEIPTN 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) 19 <br /> DATA PROCESSING COPY 9 , <br />