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STATE OF CALIFORNL-.? WATER RESOURCES CONTR'i- ,IOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM '110 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C9.,!PORN P <br /> MARK ONLY ❑ 1 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 9 / <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) go <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> Ra C- * ­r[- L 8 e_ l rV <br /> ADDRESS NEAREST CROSS STREET A ,,✓ loindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �l / ?,7, <br /> 2Rat �l YJCI.' n . L7 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> // /�,j (x ❑ INDIVIDUAL ❑ COUNTY-AGENCY 00 <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> S_�_oGlC CA 0 �v9 `f7`f - Sud <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR F—] 4 P OCESSOR ✓Box it INDIAN EPA ID # <br /> ❑ ❑ TRUST LANI DS o ❑ II r #of TANK'S I <br /> 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE <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 /> D. u.� yx 0 vieS ( .,90q) LF-71+-143 o a th-SSa3 7 <br /> NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. N (LAST,F T) PHONE#WITH AREA CODE <br /> E m e q e n C �'cvlt� � I C q 1 ?-43--77 7 7 <br /> II. PROPERTY OWNER FORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> RQCI' .-�I C Be l l <br /> MAILING or STREET ADDRESS ✓Xx to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> a a co ; Yl o 2 Cl w o rU 'gym d ��El INDIVIDUAL El <br /> ElCOUNTY-AGENCY Cl LOCAL-AGENCY El FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> ��^es c W <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA E CARE OF ADDRESS INFORMATION <br /> �4Cr���G c3ell (Fl-es/vv Fuel an t <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /11 i/ I/�� n /I�Z,� C ��' CORPORATION 1-1LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 7 T V J RvLl. � ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#,WITH AREA CODE <br /> Fneswo C_ X37 & a � K <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 /> F" I I :El I I lolol / 1 ?1 -7_Lll LDlolinl / <br /> CURRENT LOCALAGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE <br /> ?a ci - 70 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRAC(T�# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO L] 1 O d <br /> [CHECK# 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 ONLY. <br /> FORMA(3-2-88) - J , <br /> DATA PROCESSING COPY <br />