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5E�0'F�•TN\, <br /> STATE OF CALIFORNIA* ` •�••�� :�, <br /> WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM Y �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - ' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C'a(,FQR V4% <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) W <br /> FACILITY/SITE NAME /�" CARE O ADDRESS INFORMATION <br /> Zt 1 EJ SIO cNfL(t AIL LG I� ��I77 <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 100 O (� ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> ICSIjV,�tQNE#,WITH AREA CODE <br /> I CA -13�5 a <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK s <br /> ❑ 1 GAS STATION ❑3 FARM Tz 5 OTHER RESERVATION or TRUST LANDS AT THIS SITE <br /> 1:1 <br /> EMERGENCY CONTACT PERSON(PRIMARY EMERGENCY CONTACT PERSON(SECONDARY) <br /> YS: NAME(LAST,FIRST) ONE#WITH AREA CODE DAYS: NAME(LA IRST) PHONE#WITH AREA CODE <br /> NI NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 2.5 <br /> II. PROPERTY OWNER INFORM TION &ADDRESS— (MUST BBBBE'COMPLETED) <br /> NAME CAjiE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS jjj��� ��/ ✓Box to indicate ❑ PARTNERSHIP 11 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ���fLL JJ ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY NAIME- STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME QtP� CARE OF ADDRESS INFO <br /> �RATION <br /> � <br /> l <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / ❑ CORPORATION LOCAL-AGENCY ElFEDERAL-AGENCY <br /> / A"r <br /> 11 INDIVIDUAL COUNTY-AGENCY <br /> CITY NAMEn ST;T ZIP CODE PHONE#,WITH AREA CODE <br /> /�' (`�'1` <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 PE URY,AND T THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> Raj&ce—, E A wl��Ls k Le&IS r- // <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I [Z101-2-M5171 L0L0T_5Wj <br /> CURRENT LOCAL AGENCY FPCILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO //—77—o' <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: wA <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASJO.R f TANK PERMIT FORM 'B'APPLICATION(S),VSS,#S A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />