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STATE OF CALIFORNIO WATER RESOURCES CONTROGOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE `'Q.oe�'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT V5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Jr <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> uDick <br /> ADDRESS NEAREST CROSS STREET ✓Bm 00dime D PANFNEFSIIP D STATE AGENCY <br /> 51 <br /> 5� ❑ 0WRATIGN D U)CALAGE10 D FEDERAL AGENLY <br /> ❑ WMDIIAL D WUNIV.AGBIIX <br /> CITY NAME STATE ZIPCODE SITE PHONE N,WITH AREA CODE <br /> AV CA 5 r Izoq -%7-_W56 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4PROCESSOR %/Box if INDIAN EPA ID N <br /> ❑ 1 GAS STATION ❑3 FARM ❑ S OTHER TRUST(LANDS RESERVATION or ❑ of TANSY <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(UST,FIRST) PHONE It WITH AREA CODE <br /> rmdki.vCly-gaN R09'-Y67 —3y3& <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> olde- C C 61 <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> QCO ,u D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME ST ZIP CODE PHONE N.WITH AREA CODE <br /> G s,Ac 1-9700-' ;�3y <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME�eMe CARE OF ADDRESS INFORMATION <br /> rJ <br /> MAILING Or STREET ADDRESS ✓Box loindicale D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY _ <br /> CITY NAME STATE ZIP CODE PHONE N,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 /> A ) DATE <br /> D.E -b�2z2ro <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION R AGENCY R FACILITY 10 N Nat TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE N WITH AREA CODE <br /> /3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTU <br /> N SUPERVISOR-DISTRICT CODE BUSINESS PN FILED DATE FILED <br /> .23eSo 32 YES ❑ NO ❑ 6Z 1 <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: +' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASII(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OFSITE INFO-RMATION ONLY. <br /> �FORM A(3i2 �6A \ 0 <br />