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r . � -7.S.S' Ol(al <br /> t S <br /> STtall R of .. <br /> WATER RESOURCES CONTRuL BOARD <br /> 10 , <br /> FORM `AMAY 2 1 t,, <br /> ,4NDERGROUND STORAGE TANK PROGRAM °L _o <br /> S[TERONMENT bi-4/SITE, INFORMATION and/or PERMIT APPLICATION ...� <br /> PERMIT/SERVICES COMPLETE THIS FORM FOR EACH FACILITY/SITE "FOR <br /> MARK ONLY ❑ I 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 Q <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> O� <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> P,kc,/FI S FL _ <br /> ADDRESS NEAREST CROSS STREET v/Box toindrale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> [5?LCORPORATON ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 6/,3/ c/E 16 AVE. PO/27-6,12 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE It.WITH AREA CODE <br /> 5-TockTvnl CA 9.�ao 7 L)L217- 9Sa - b.s'8/ <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR7B..VLjfAlIDIAN EPA ID aON or A of TANK's <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER DS ❑ AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> PA7 i E,2sa t4 ,, 7A iiYA o9- 9sa -Gs9/ -5/14A`4 pQLA n)07- Y)7 -ODD <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA COD NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Pi4 svi.l ✓� 09- 5'7) E as 7 - 2_5 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 NF,LL /L mpA4e,1Y- Sqj* , <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /� <br /> .)&CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCYP•v. o O�3 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> Gv,1`11 CORD CA I9vsa 9 I k-///� 7 6-/V//-// <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S ELL 0/4- 609')Pp}N S<+•I,F- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 53-CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> P <br /> .0. Q 4-1Ooh 3 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> CO N I:02 0 C4 9vsa 91 (a -iyiy <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.JZ 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 NATURE) -dDATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION 8 AGENCY M FACILITY ID k #of TANKS at SITE <br /> = Z I 2 E5 1-3 1 <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> ?� <br /> [ERIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> TION CODE CENSUS TRACT K SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z3 (.oC) Z YES ❑ NO C j� <br /> K M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a BY: <br /> i <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 /> j j j 1 DATA PROCESSING COPY >� <br />