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Vii: TE OF CALIFORNIA WATER RESOURCES CONTROBOARD '` .. .:` <br /> FORM 'A':, UNDERGROUND STORAGE TANK PROGRAM a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE - <br /> MARY(ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE MJ' <br /> ONE ITEM E12 INTERIM PERMIT Y AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE 1 O __41. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 1 O 00 <br /> 00 <br /> FACILITY/SITE NAME Ln <br /> CARE OF ADDRESS INFORMATION <br /> e o )a <br /> ADDRESS <br /> NEAR STREET CRO SSTREET ✓ b,Ylua 0 PARTNET&W 0 STATE ABDO <br /> V st / CONORAT1ON ❑ LOGLAGEHp ❑ RDRUI AGDIGY <br /> CITY NAME Q INIXVId1N 0 OGATYAGFNC/ <br /> STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> 0'.j CA q5 p <br /> TYPE OF BUSINESS: p DISTRIBUTOR =EMAox itINDIAN EPA ID pI GAS STATION 3 FARM RVATION or ❑ - ♦oI TANK4ST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> ,___�/ �_Z�SZ PHONE N WITH AREA CODE <br /> rru%\ Gam+/�t ✓ee _ <br /> NIG TS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> SAMC- as a 5'a�wc a(on,.av - vg- <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> to <br /> MAILING or STREET ADDRESS C,� r <br /> to indicale ❑ PARTNERSHIP <br /> 0 STATE-AGENCY <br /> O 7 V RPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> IVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAM E �' STAZIP CODE PHONE N,WITH AREA CODE <br /> +,_S -qv8-z(s <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate <br /> 11 PARTNERSHIP 0 CORPORATION 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE A.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: 1. 0 Ii. 111. <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 /> CmNTY S JURISDICTION M AGENCY M FACILITY ID S S of TANKS at SITE <br /> �J = = 6 D / © 1 O <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE It WITH AREA CODE <br /> serail <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Q( <br /> 213 AYES"iNO ❑ <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y <br /> BY: <br /> ass- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1�MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A <br /> FORMA(3-208) CHANGE OF SITE INFORMATION ONL <br /> DATA PROCESSING COPY <br />