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STATE OF CALIFANIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> s <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `+i�Fo�_�P <br /> MARK ONLY 1 NEW PERMIT E]3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT q AMENDED PERMIT 06 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FA LITV/SIT NAME C EOF ADD ESS INFORMATION <br /> E (nom Com an "ID �cUv1a os6ns+e e.l � <br /> ADDRESS N REST CROSS STR T ✓gayainMzle ❑�yyARTNEASHIP ❑ SiATEAGENCY r <br /> Zq W. March �c e Q ��,y )V ❑ CORPORATION VA TATE <br /> ❑ RDEA AGENCY <br /> ❑ INDIVIDUAL ❑ CDUNT/AGENCf <br /> CITY NA E STATE ZIPCODE <br /> SITE PHO E#WITH AREA CODE <br /> ✓✓�I V� CA �152� Zo�i)961 - 8303 <br /> TYPE OF BUSINESS: p DISTRIBUTOR 4 PROCESSOR ✓Dox if INDIAN EPA ID # <br /> I GAS STATION 3 FARM OTHER RESERVATION or ❑ �_ #of TANK't /1 I <br /> TRUST LANDS ATTHIS SITE l/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Q t. on � <br /> NIGH N ME(LAST,FIRST( PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> a �. 6n d� <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> N ` of S-toCK+on �IY� �� '� CAREO ADDRESS INFORMATION <br /> MAILING orS REET ADDRESS ✓Box lo,Yocate ❑yygRTNERSHIP ❑ STATE-AGENCY <br /> `I 5 E Dorado ❑ CORPORATION VLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> ^^1 ' ^ STATE_ ZIP CODE HONE#,WITH AREA CODE <br /> (� 11 l/�' q52 oZ 269JgyN- S2 1 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAyyi1 v-F �hocK+b n �` -�. CARE OF DDRESS INFORMATION <br /> r-obw <br /> MAI/IILIJ'G orTR'EET ADDRESS rr ✓Bax Lo intlicale TL ❑yARTNERSHIP ❑ STATE-AGENCY <br /> Z,J I� G 1 �brGl� ❑ CORPORATION Br LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE N ZIP CODE PHONE#,WITH AREA COD <br /> CA q 5Z az 70�) 9 K4- �Z T) <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: f. if. 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3 q o 0 2 y o 1 0 0 0 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> EN9LIN Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> OCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FIrED <br /> 231GJ0 32 YES ❑ NO <br /> PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> BY: AAS�O <br /> V` <br /> (�) <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UN THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORA 3-2-BB) <br /> M ( <br /> //(/f ; <br /> _9 I DATA PROCESSING COPY 12 f <br />