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STATE OF CALIFORNIP WATER RESOURCES CONTRISPOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM a .o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 95 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) C7 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Na S <br /> ADDRESS - NEAREST CROSS STREET ✓Dw 0 Mule 0 PARTNERSHIP 1:1STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL AGENCY 0 FEDERALAGENCY <br /> ✓' + -r/ <br /> Yo. ❑ INDMDWL ❑ COUNTY AGENCY <br /> CITY NAME — STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> Giti 'Pi•� CA 5236 <br /> TYPE OF BUSINESS: 1:12 IBUTOR ❑ 4PROCESSOR '/Box if INDIAN EPA ID a of TANK'e <br /> ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUSTYLANDS or <br /> ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(IAST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> EUQ Nc� � T L <br /> MAING or STREET ADDRESS� / ✓Boz to indicate 0 11PARTNERSHIP 0 STATE-AGENCY <br /> .22'/ 'nY^J(, ❑ CORPORATION LOCAL-AGENCY C3FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> G>+5✓PN C� <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> N CARE OF ADDRESS INFORMATION <br /> e cs <br /> MAILING or STREET ADDRESS I/80x 10,ndicele ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k WITH AREA CODE <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. ❑ II. 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 k JURISDICTION M AGENCY M FACILITY ID R R of TANKS at SITE <br /> 41 o0 17 1 <br /> CURRENT LOCAL AGENJPY FACILITY F a APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 5_ YES E] NO 6414S" <br /> s C'741— <br /> CHECKM PERMIT AMOUNT SURCHARGE AMOUNT 7 <br /> E CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), USS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />