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STATE OF CALIF'ORNI wATER RESOURCES CONTRLOARD <br /> f <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G t COMPLETE THIS FORM FOR EACH F CILIYY/SITE a+` <br /> MARK ONLY ❑i NEW PERMIT ❑ 3 RUIEWAL PERMIT E!21CHANGE OF INFORMATION 7LEESUAbOTLY CLOSED SITE W <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ I AMENDED PERMIT ©6 TFMPORARY AITF CI OAI IRF <br /> L FACILITY/SITE INFORMATION 6 ADDRESS—(MUST BE COMPLETED) <br /> FAC#ITY/RITE NAME <br /> n Cnge of wppgE091NFORMATION <br /> ADDRESS 1l1�A�4)D/� NEAR' <br /> STREET ✓Buthl NEtNA YygIENP)P 11 StATEAWO <br /> 1 l NbA- P�fC<.—T s7 ws I N6, p I ,NH omw o o�T M mmN. iw <br /> CITY NAME �'j�./! STATE ZIP CODE <br /> TYPE OF BUSINESS: •�j SITE NE/Y W17H ApgE+AyCA�p/� <br /> CA ;I�� !AD O y a y �J <br /> ❑2 gSR11BUY0q ❑x P $90R ✓BD#a INDIAN <br /> EPA ID x <br /> ATIN❑1 GASSIATION ❑3FARM TRUST LANDS cr ❑ ATTHISSRE r <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: (LAST,FIRST) PMONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> Zol <br /> NIGHTS: NAME(LA fltsTl_/4r PHONE x WITH AREA C50DE NIGHTS: NAME(LAST.FIRST) PHONE#WITHAREACOOE <br /> 11. PROPERTY OWNER INFORMATION A ADDRESS —(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING aSTREEYADpRESS ✓Box to lMltdle ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> D g(J 3 Q ❑ CORPORATION ❑ LOCAL,AGENCY D FEDERAL-AGENCY <br /> CITY NAME Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> sTAre - ZIP CODE�.�� PHONE k,WITH AREA CODE , <br /> Ill. TANK OWNER INFORMATION&ADDRESS — (MUST BE COMPLETED) y <br /> NAME <br /> n--- ^ CARE OF ADDRESS INFORMATION <br /> MAIUNO aSTREET ADDRESS VVA"Y�L ✓BO 10 indlcme PARTNERSHIP 11 STATE-AGENCY <br /> Q CORPORATION ❑ LOCAL•AGENCY © FEDERAL.gGENCY <br /> CITY NAMF ❑ INDIVIDUAL Q COUNTY•AGENCY <br /> STATE ZIP CODE PHONE W.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOYEADORESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1, ❑ II. ❑ III,❑ <br /> THIS FORM HAS BEEN COMPLC7•CD UNDER PENALTY"OF PERJUHY,AND TO THE SEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 6 McNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY lY JURISDICTION 0 AGENCY R FACILITY ID Y <br /> �--~� Y o1 TANKS At SITE <br /> L L-LJ �© / '3 pada <br /> CUgRENT L AGENCY FACIUTY ID Y a <br /> APPROYEDypy NAME% PHONE Y WITH AREA CODE <br /> r� <br /> PERMIT NUMBER PEgMITAPPROVA4 DATE <br /> PERMIT EJ(PIRATION DATE ' <br /> LOCATION CObE CrNSI1B MACrA SUPenrWON•OISTRICT CODE . "" <br /> Q G� BUSINESS PLAN FILED DATE PILED <br /> CHx;CKY PERMIT AMOUNT SURCHARGE AMOUNT YES NO /����� <br /> FCE CODE <br /> jRECEIPTY <br /> Bv. <br /> THIS FORM MUSTBE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'EI'APPLICATION(S),UNLESS THIS I$A CHANGE"SITE INFORMATION Y. <br /> �.,J FORM A(S•i•BSI <br /> q <br /> DATA PROCESSING COPY <br /> I <br />