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STATE OF CALIFORN19 WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM ' <br /> S FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION ❑ 7 PERMANE TLY CLOSET)SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> C.0I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> N <br /> FACILITY/SITE <br /> r � NAME CARE OF ADDRESS INFORMATION <br /> i C.n iAQ. WM Ci # I.c. I CI� �T J�Cx 7(J Yl <br /> ADDRESS - NEARS C�IOSS STREET ✓BOKb ididl13e PARTNERSHIP ❑ STATSAGENCY <br /> �IOIO E' 1 • I�Y� IIQQ�+ �j(J.� ❑ CBNPlHl4iION FLOG AGENCY ❑ FEDB4LLAGDV <br /> ❑ INDMDUAt ❑ COUNTRAGENC! <br /> CITYNA�+E STATE ZIP O � SITE PHONE#,WITH AREA CODE <br /> �tpck+dr� CA dl �o, ZO�i 4{l0l0 214 <br /> TYPEOFBUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓BoxdINDIAN EPAIDa <br /> ❑ If of TANK's <br /> I GAS STATION ❑3 FARM N'0THER RRUST LANDS Dr ❑ AT THIS SITE b <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME( T,FIR�S/T)� PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1 V l <br /> dAkki <br /> NIGHTS: NAME"ST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAM PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME . /T 4 CARE OF <br /> 1 a�j�C7Li FB B 10 <br /> O } <br /> m 6Yl <br /> MAILING or STFI ADDRESS ✓Box to indicate PARTNERSHIP 11STATE-AGENCY/ <br /> , 1 I O a Y-C)A Fm 31� 11 CORPORATION Id"LOCAL-AGENCY 11FEDERAL-AGENCYElINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME lV STATS ZIP CODE PHONE N,WITH AREA ODE <br /> Cv„L(1�1 /l¢_ gsao a a09 qW �� <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NA CAREOF DDRESSINFQRMATION <br /> 1 ��letFsl�J (Tll LV_�I'V"IL L/1r/Tl <br /> MAILING orS REE^T ADDRESS' i �F Box to indicate El 13 PARTNERSHIP 13STATE-AGENCY142-51 1 C+I OOY 1�M �1 11 NDIIVIDUALION El COUNTYAGENC 11FEDERAL-AGENCY <br /> CITY NAME ST(L ZIP CODE PHONE N,WITH AREA CODE <br /> S+oc,lk4vn gSD.o,� 209 944%2.1l <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: 1. ❑ If. 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> E�l 10101,1- `� C) 10 -k <br /> CURRENT LOCAL AGENCY FACILITY ID N APPgOVED BYNAME PHONE N WITH AREA CODE <br /> 240 <br /> PERMIT NUMBER - - PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> DE CENSUS TR M SUPERVIS R-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3VEJ�/\ pili YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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 ONL . <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />