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IV. J.1a--T*lji {.fT .: :lxI_l 'I),p.. 'yff...f .nj`.TFa-,n.•.r <br /> STATE OF CALIFOR% WATER RESOURCES CONT%t OARD <br /> FORM `A': =f <br /> UNDERGROUND STORAGE TANK PROGRAM n, <br /> SITE FACILITY/S�jE, INFORMATION and/or PERMIT APPLICATION I a <br /> G - COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEWPERMR - ❑ 3 RENEWAL PERMfT �5 CHANGE OF INFORMATION ❑ 1 PERMAtiE.` CLCLOOS'IED SITE I--� <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ A AMENOEDPERMIT ❑6 TEMPORARY SITE CLOSURE V <br /> CT1 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N <br /> a) <br /> FAL'A.ITY/WEHAM CARE OF ADDRESS INFORMATION II <br /> S NS 04ui)2. <br /> ADDRESS 11[ NEAREST CROSS STREET <br /> Q ❑✓ftbeF ION ❑ `�Y ClST�uE <br /> 140 f u •1I`-� LIhkC Al �* INDMWAI ❑ C : 'A'>1;.1' <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> s_h:)Izk6 IQ CA o tAT 6 - 6 <br /> TYPE OF BUSINESSr ❑ 2 DISTRIBUTOR F-14 PROCESSOR ✓Box i11NDIAN EPA ID N <br /> RESERVATION or of TANKt <br /> I GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE <br /> N Al kn -1V6 04N <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIG TS NA E(LAST,FIRST) PHONE-WITH AREA CODE <br /> cao9 :951—/?5 U1C <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA CII CARE OF ADDRESS INFORMATION <br /> I NAW K6r <br /> MAILING or STREET ADDRESS ✓Box to indicate 11 PARTNERSHIP ElSTATE-AGENCY <br /> �� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> M1M1[[ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY E STATE I ZIP CODE K PHONE N,WITH AREA CODE <br /> C24 1 5/ <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME �(�/ CARE OF ADDRESS INFORMATION <br /> SlowQ �S / 1 <br /> MAILING or STREET ADDRES Be.✓ toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> ICHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II 111.❑ <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 M JURISDICTION# AGENCY R FACILITY ID N N of TANKS al SITE <br /> 0lo1 1 Eolololol <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA`ODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAFIL D <br /> 232 v res ❑ No ❑ I (Oil C-4 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> ITHIS 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 /> YFORM A(3-2.88) <br /> DATA PROCESSING COPY <br />