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t <br /> StATE OF CALIFORA WATER RESOURCES CONTR L BOARD A h`P l4 QAA ref <br /> FORM `A'. i <br /> 1��1DERGOUND STORAGE TANK PROGRAMMme fto <br /> ITE FACILITY/SITE,INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `4l,FORN�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 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS—(MUST BE COMPLETED) <br /> FACILITY/SITE NAME � CARE ADDRESS INFORMATION <br /> '5K z 1 j i t N1 L(t AIL. r_ i! g• <br /> ADDRESS NEAREST CROSS STREET ✓86biweb ❑ PARfNBISFNP ❑ $TATE-AGENCY <br /> ❑ COIPMTION Q LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INI M MAL COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODESIT HONE If,WITH AREA CODE <br /> G CA 95231 - �! p <br /> TYPE OF BUSINESS: r__j 2 DISTRIBUTOR4 PROCESSOR I ✓Box if INDIAN EPA ID N19- <br /> 151 A Of TANK's <br /> ® 1 GAS STATI�1 [—]3 FARM 5 OTHER TRUUST LANDS RVATIONor ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D&YS: NAME(LAST,FIRST) ONE#WITH AREA CODE DAYS: NAME(LA IRST) PHONE k WITH AREA CODE <br /> C I£.6Z N <br /> NI NAME(LAST,FIRST) ONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ZA <br /> 2,5� <br /> 11. PROPERTY OWNER INFORM TION &ADDRESS-(MUST B,E'COMPLETED) <br /> NAME ' CA E OF ADDRESS INFORMATION <br /> %%, x(21 iia Z.($ <br /> MAILING or STREET ADDRE S ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> '`+✓ ❑ INDIIVIDUACORPOLION 19 <br /> COUNTY AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAW STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION&ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFrRATION <br /> I,� 1 L <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑A� CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY❑ INDIVIDUAL COUNTY-AGENCY <br /> ' CITY NAME STATJn ZIP CODE PHONE k,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t I BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. E IL El UI.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P5pjURY,AND T THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> FlAPPANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> ENBER <br /> JURISDICTION# AGENCY# FACILITY ID S A of TANKS at SITE <br /> 0 <br /> ENCY FACILITY ID R APPROVED BY NAME PHONE R WITH AREA CODE <br /> R C, k 10 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEDYES ® NO ® -7,7rPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT K BY: `_ <br /> THIS FORM MUST DE 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) <br /> DATA PROCESSING COPY <br />