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STATE OF CALIFORNO WATER RESOURCES CONTRAOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o p <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE - <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1<5 <br /> CHANGE OF INFORMATION ❑ 7 PERTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE yJ' <br /> 40 <br /> I. FACILITY/SITE INFORMATION A ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME Sea JKe S CARE OF ADDRESS INFORMATION <br /> DI,)A fQabex R.o eIt ro <br /> Ff�REST CROSS STRET ✓Box to m0icale PARTNERSHIP DSTATE AGENCY <br /> ADDRESS / ST D COAPOAATION ❑ COCALAGEEN ❑ FEDERAL AGENCY <br /> J VWw D INDIVIOIIAL ❑ COUNT, a) <br /> CITY NAME V�O }'�� / _ <br /> STATE ZIP CODE����� SITE PHONE k.WITH AREA=7 E W <br /> TYPE OF BUSIrvESS'. ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # Alto f TANK'#; <br /> RESERVATION or AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> N; 6 y�l8za5 � <br /> NIGHTS: NAM LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> l/ 2117 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 44) <br /> MAILIN ar STREET ADDRESS P <br /> Box to indicate PARTNERSHIP D STATE-AGENCY <br /> C 0 O M S J CORPORATION ❑ LOCAL AGENCY El FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME /// STATE ZIP CODE <br /> 'J�) �. PHONE <br /> 9# TH AREA <br /> /CODE <br /> - S /V✓lam W C A '„i ZV V C/Z <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME � " CARE OF ADDRESS INFORMATION <br /> �p/V f Lleo' 441# <br /> ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> GS� ❑ CORPORATION ❑ LOCALAGENCYENCU [IFEDERAL-AGENCY <br /> -1D INDIVIDUAL COUNTYAGENCY <br /> CITY NA E STATE 21P COOE - PHONE N.Wi FREA ODE•-��Z <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. ❑ IL III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> AP ICAN 'S NAME(PRINTED06 851 ATURE) DATE/��—! e/ <br /> LOCAL AGENCY USE ONLY (B (] <br /> COUNTY# JURISDICTION# AGENCY k FACILITY ID# #of TANKS at SITE <br /> FJ—orZ- 2 6 v F 391 v o <br /> CURRENT LOCAL A2pCY FACILITY 10# <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER FF PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT#� SUPERVISOR ISTRICT CODE BUSINESS PLAN FILED ❑ DATE FILED — <br /> 2D YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p 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) • <br /> • DATA PROCESSING COPY <br />