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STATE OF CALIIFORNi, WATER RESOURCES CONTRVBOARD <br /> FORM 'A': ' <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o':;�, 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C���fppN <br /> FMARK ONLY ❑ � NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I ♦rl <br /> I. FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) <br /> 00 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFOR ATION <br /> S+eut & GPI>Ps J V/G-2 P /urs <br /> ADDRESS NEAREST CROSS STREET ✓ TION ❑❑ L Q STATEAGM <br /> - <br /> 231 S S � 6MO(o VI/S � #IOIVIOUAL ❑ mlm4mla <br /> CITY NAME STATE W CODE SITE PHONE It.WITH AREA CODE <br /> Sfior-++0.1'1 CA 1..9_09-,W3:_W26 <br /> TYPE OF BUSINESS: ❑2 DISTR16UTOR ❑4,MIOCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or AT THIS SITEIf of TANWs <br /> i ❑ 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS ❑ /V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIG TS: aNAM,, LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> � Pe �kN <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME - _ CARE OF ADDRESS INF ATION <br /> c, i,�s _ve, <br /> MAILING or STREET ADDRESS -/a x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> S ,J ORPORATION ClLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Ci( INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> s a - �6 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> lame- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ---❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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: L 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 /> FPGRMITNULIDER <br /> N JURISDICTION k AGENCY N FACILITY IDN N of TANKS at SITE <br /> Ldo � o o kod <br /> CURRENT AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA COOS <br /> E�3 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 $0 $ YES ❑ NO ❑ C p gr'PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY. b <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 ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY ).,� <br />