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TATE OF CALIFORNIA - <br /> O Nlld► WATER RESOURCES CONTROL BOARD <br /> W: <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM , <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION za' 0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C9 i.FORN%' <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F^'a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE d ­4 <br /> CJ1 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) fV <br /> CTI <br /> FACILITY/SITE NAME _ r i n0 CARE OF ADDRESS INFORMATION <br /> 1 <br /> ADDRESS NEAREST OSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> y� as �CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> S ^ 7 r f I•�0� 11�J S ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODESITE PHONE#,WITH AREA CODE <br /> i ar. CA '3iC� 2r_ft --'535= <br /> TYPE OF BUSINESS 2 DISTRIBUTOR ❑ 4 PROCESSOR [R�FSBE`R�IL�A <br /> tINDIAN EPA ID #GAS STATION 3 FARM 5 OTHER TION orATTHISSITE9-1 ❑ TRUST ANDS ❑ <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 /> ClO 2 cK - '3S 7 7'7.7 Aro tOU41.� 9d 0 - ,�/— S <br /> NIGHTS. NA E(` ST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Se- cc r 6 7 - 2-2---16-69' 4,rro re ?Pd -Cr.2 J- Z15 <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �1 Flower <br /> CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> -p-i� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER iNFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CAR OFADDRESS INF MATION - / <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ( CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> V J ❑-I INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAE STAT ZIP CODE PHONE#,WITH AREA CODE <br /> —367 <br /> -- I <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. ❑ 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 /> d <br /> Ell oloEl_ <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Ilk r-,i5, .1i S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> _23 , �C� L YES ❑ NO ❑ C ( / �� vim(' <br /> CHECK M 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 0 <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />