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{ <br /> PSTATE OF CALIFORNI WATER RESOURCES CONTRO OARD <br /> W. •;SA <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM Y a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° Ia <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE CaI,FpRN P <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION El PERMANE LY CLOSED SITE F"'► <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 8,)- <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> L � r--4 1 •�S l I o tia <br /> ADDRESS f —/� NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> 1 0 LOCAL-AGENCY-7 4 C / _ 1 1^r" O H A fes) p NDMDUALIDN ❑ COUNTY AGENCY El FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> --or CA s 3 3 (2) <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESE❑ ❑ TRUST LANDS ATION or ❑ #of HIS SITE OKI 1 GAS STATION 3 FARM 5 OTHER 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 /> ❑ d .�,.— clA z 37-1141 /LI,K,e Ywfc// 6cn\ 23? -Z0047 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11, PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME �t J� CARE OF ADDRESS INFORMATION <br /> (E j� <br /> l A— <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> A 1 ❑ CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 1 8 3 Iv (� A i k__3 &'INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> G� s _L 1 q l <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> E 4 ( .4 CL <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> a ' " <br /> 1:1 CORPORATION ClLOCAL-AGENCY ClFEDERAL-AGENCY <br /> Q' 3 )V o ..G� 1 iJ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> N�� .v 5 C 4� 3 3�o <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 /> APP CANTS NAME(PR TEI�'&�SIGNATURE) DATE <br /> �r� (//l <br /> zt4�2 <br /> 1 <br /> LOCAL AGENCY USE NLY <br /> COUNTY# JURISDICTION# AGENCY# FACILI ID# #of TANKS at SITE <br /> ® 0 � 3s3lo [D lo I I <br /> CURRENT LOCAL AGENCY FACILITY ID# APP BY NAME PHONE#WITH AREA CODE <br /> PERMITMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 1-1 P, I <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRIC CODE BUSINESS PLAN FILED DATE FILED <br /> � � YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <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 />