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O <br /> STATE OF CALIFORN WATER RESOURCES CONTRRRRRRRPBOARD <br /> / .'•BEV N[M�•. F <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM stlo <br /> SITEE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - ; ,, 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE OF <br />!f <br /> I MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE I-+[ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - g CDA <br />{ I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) Cn <br /> FACILITY/SITE NAME 4p CARE OF ADDRESS INFORMATION <br /> S' /1'l L f5 - 5-7(1-5- <br /> ADDRESS NEAREST CROSS STREET ✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / <br /> CORPORATION 1:1 LOCAL-AGENCY ❑ FEDERAL-AGENCY/(,i �� , ✓ f iczr1e / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA ys3 -was/ <br /> ;TYPE OF INESS: 2 DISTRIBUTOR ❑4 PROCESSORTRESERVATION <br /> ox if INDIAN EPA ID # <br /> or #of TANK' <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER ST LANDS ❑ /�O N AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> E <br /> DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NA..._�WSI,FIRST` T� ___PHONITl WITH eaFAt=NAMEIRST) PHONE#WITH AREA CODE <br /> C s� eve is <br /> II. PROPERTY OWNER INFORMATION &ADDRESS= (MUST BE COMPLETED) <br /> CNAME CARE OF ADDRESS INFORMATION <br /> A,11000 le Sf l C e <br /> MAILING or STREET ADDRESS ,Jilo✓ to indicate ❑ PARTNERSHIP STATE-AGENCY <br /> r [� / CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> i tJ 77_ - /��� T Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> v f 9gS-3 `l �/s37 <br />{� III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> k NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br />` ❑ INDIVIDUAL ❑ COUNTY-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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.❑ <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(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> f <br /> F <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> o C� / 7 F�j © I ® I ® 02 <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT BUSINESS PLAN FILED DATE FILED <br /> 'oa `gO � YES NO PERMIT AMOUNT SURCH AGE AMOUNT FEE CODE RECEIPT# Y: <br /> i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM`B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />