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ORR <br /> r1 _ <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROLARD BSEP'°?0�, '"f <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM r A-o <br /> SITEr4--7FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °"kiFORNNP <br /> F <br /> ARK ONLY ml <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMAN ED SITE � <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> (z D <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) co <br /> 4 <br /> FACILITY/SITE NAME 1 CARE OF PDRESS INFORMATION <br /> �i . libUlttli� ��? <br /> OF <br /> Ma1'��. zVIA <br /> ADDRESS NEARE T CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEITE P ONE#,WITH AREA CODE <br /> CA 44v,2 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID #RESERATION #of TANK's <br /> I� ❑ 1 GAS STATION [:]3 FARM "K5 OTHER TRUST LANDS or ❑ f`�' /r AT THIS SITE I <br /> I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> k DAYS: NAME(LAST,FIRST) PHONE At WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> q47 -2ao a <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> C <br /> &r.. '�p 00�'CIx--' (-20 q)A477--2..;w:p 0---d4e. <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF APDRESS INFORMATION <br /> fit, t7oMly�li� ' OF N �/�1 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ( ✓ <br /> N. //+� }^�,.�i ,t� G���—r� .l ,..� X CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Z/V✓ t�Vil1T/W�J m 40 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> .(CTOJ�I G4 a1��9- 4{01- b3R0.a <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br />( NAME I CAR, F ADDRESS INFORMATION <br /> �C. 11.E ilh t-bSA ! ftiM.S"CLR /N✓// <br /> MAILING or STREET ADDRESS {�✓/Box to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> CORPORAT0 LOCAL-AGENCY <br /> %ft� tl. &:kLAV QiA ) �)�" 40- LJ NDIVIDUALION ❑ COUNTY-AGENCY El FEDERAL-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 A ES HOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. if. III. <br /> THIS FORM HAS BEEN COMPLETED UN ER EN LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNAT R ) DATE <br /> LOCAL AGENCY USE ONLY <br /> I <br /> FPERN <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> Ll 1 1 10101,2- 13 ©Io-T-1 <br /> AGENCY FACILITY ID# APPROVED BY N ME PHONE#WITH AREA CODE <br /> ki <br /> PE MIT APPROVAL DATE PER IT EXPIRATION DATE <br /> i <br /> CENS TRAC # SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3� YES ❑ NO .�►j &16/k7PERMIT AMOUNT SURCHARGE AMOUNT7iic <br /> ODERECEIPT# BY: <br /> "HIS FORM MUST BE ACCOMPANIED BY AT L ST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FG;1M A(3-2-88) • DATA PROCESSING COP <br />