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m a y - L13 Sy' <br /> STATE 9A# WATER RESOURCES CONTROL BOARD <br /> oF <br /> �•• 'EV F[M�••,F <br /> FORM `A': <br /> MAY 2 1 19NDERGROUND STORAGE TANK PROGRAM _ Mla <br /> SITE ENVIRONM NITTAUM, INFORMATION and/or PERMIT APPLICATION Y a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE RO <br /> PERMIT/SERVICES C'al�FO RNP <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PER SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION y� <br /> Cv/ Olt- nl C, syqmf. <br /> ADDRESS NEAREST CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION 1:1 LO ❑ FEDERAL-AGENCY <br /> r / WfwQ W7le/sINDIVIDUAL El COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> or_, -ool CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID# <br /> RESERVATION or #of TANK's <br /> bd 1 GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> CGoY G Nl(,k doy-zlk(o- lQo/ :qW &0YWj CHIS aOg- 4166/90/ <br /> NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA C DE <br /> GoYAr&I1(,k y��- ��6- �o� Gori C Is /91_-91&q �e <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �tCct_ Olt c w)pANY 5AmO <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> t1WCORPORATION 13LOCAL-AGENCY ElFEDERAL-AGENCYP. 00)3 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> D I clqfay <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 116tt Olt comp9 i'llY C- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> - :CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> yoo�3 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> co r4 C/O 4D C4 IV go-)9 iii > -ly/y <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. ❑ it. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICAN 'S AME(PR NTED&SIGNATURE) DATE <br /> CZ 41 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> o5- <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �r�"fid 7i <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT#/ -w SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> '�/Z/16 z YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> (i E' its <br /> IS FORM MUST BE ACCOMPANIED BY AT V(1)OR MORE TANK PERMIT FORM `B'APPLICATION(,ONLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FO A(3-2-88) <br /> ��� t DATA PROCESSING COPY <br />