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STATE OF CALIFORNil WATER RESOURCES CONTROL BOARD <br /> `'�P•iuAik�•T�p <br /> FORM `A': �` ��•s=� t <br /> UNDERGROUND STORAGE TAN PROGRAM =`� � m <br /> SITE ACILITY/SITE INFORMATION and/or RMIT APPLICATION - �� <br /> rea <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE �FORK" <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE pZ Cn <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) . <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION OX $'9 QEN4J C <br /> 57J oe-F 4 )46- Q u'� SToP KKK r 0e /zs' �41107) <br /> ADDRESS NEAREST CROSS STREET ✓Boz to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> 1;g_�XORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> , A) �TO E R 1) INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> /PV N/ CA 9-5-346 zap-s9y-;2-2--s1 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTORI PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> RESERVATION or <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE- <br /> ,� eosT lJTi/L�c� Zoe-5191-1- -L-z hCK <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LA T,FIRST) PHONE If WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> * P KGTSZ P © , ;2EI'h ON i -1 <br /> j MAI G or STREET DDRESS ✓ ox to indicate 1-1PARTNERSHIP 11STATE-AGENCY <br /> -CCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / T 7 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#,WITH AREA CODE <br /> 2 � <br /> F- E dw �. CSE Vs� 7 L115 <br /> I11. TANK OWNER INFORMATION &ADDRESS ST BE COMPLETED) <br /> NAM �� ,I-N4A � C `z);DDRE�$Io)OCRMATION ��� Fwc—ma (/ �) <br /> 31 <br /> M NG or STREET A DRESS L4 ox to inld/ioJate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> IVIDUAL ❑ COUNTY-AGENCY <br /> I'I CITY NAME ZIP CODE PHONE#,WITH AREA CODE <br /> /1i AT i% �i>. F <br /> IV. LEGAL NOTIFICATION AND BILLING ADDR & <br /> CHECK ONE(1)BOX INDICATING WHICH A06VE ADDRESS SHOULD BE US LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. Ill.❑ <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�(�PRINTE7D&&SIGN URE) yC DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 7 Lo I o I ol <br /> I <br /> ENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> IT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> TION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a 3 S-_0 YES'❑ NO ❑ 2ir� r �. <br /> K# PERMIT AMOUNT SURCHARGE AMOUNT 7FEE CODE RECEIPT# BY: �( 0— <br /> DO <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST OR MORE TANK PERMIT FORM `B'APPLICATION(S),UN ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> `� <br /> 3 a_(­� 1 DATA PROCESSING COPY ri <br />