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� <br /> [ <br /> �OF <br /> yEP• rh <br /> STATOWA IA WATER RESOURCES CONTROL BOARD <br /> MAY 2 1 1900 <br /> FORM `A': `� ERGROUND STORAGE TANK PROGRAM <br /> SITE"VIRONMEi�lT, 1 /SITE, INFORMATION and/or PERMIT APPLICATION <br /> PERMITA �S. COMPLETE THIS FORM FOR EACH FACILITY/SITE IFORN" <br /> MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANOTLY CLOSED SITE <br /> ONE ITEM 1:1 2 INTERIM PERMIT 1-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) C <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Pi% y <br /> ADDRESS NEAREST ROSSSTREET�— /A Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> SOD , / o O� Q 'Q fEIVIDUATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> u Y� J CC�i I'I' &yt NO, INDIVIDUAL ❑ COUNTY-AGENCY <br /> _,j�CITY NAME / STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Lodi CA 9�� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID# #of TANK's S <br /> 5 OTHER RESERVATION or AT THIS SITE <br /> d GAS STATION [—] 3 FARM E] TRUST LANDS <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 /> swj*K _o"l Zo9-3L�$32s" ceff s <br /> 2D - 8-3�s' <br /> NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME ST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS -(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Se ©i � <br /> ✓ ox to indicate <br /> MAILING or STREET AD RESS PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 3 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONWITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE FADDRESSINFO ATION <br /> S/IG i Olt <br /> t MAILING or STREET ADDRESS ✓�ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> NJ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STAT ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME A / —` A,5-- / P76 <br /> — I <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICN 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 /> APPLICA 'S NAME(PRINTED IGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> F T Rl I I I J Ll I 1 010 -1 1 <br /> CURRENT LOCAL AGENCY FACILI 1 # 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 <br /> CHECK# PERMIT AMOUNT SU ARGE AMOUNT FEE CODE RECEIPT# 8Y <br /> fF <br /> THIS FORM MUST BE ACCOMPANIED BY AT L 1)OR MORE TANK PERMIT FORM`B'APPLICATIONS ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> e FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />