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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 'tx "" <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'"��e"'" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 5o O <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) I j <br /> FACILITY/SITE NAME CARE OF ADDRESS INFO MATION <br /> I erMI <br /> 11(worf 1'f4rC. . �i�/e <br /> ADDRESS //�� /1 NEAREST CROSS STREET ✓BmbiUwM 0 PARTNERSHIP 0 STATE AGENO <br /> rl 3b Chi�t OIYWGL ❑ Ca AMTION 0 LGCAL*.EN.Y 0 FEDERAL A.GDO <br /> ❑ #NOX 0 W.01TY AGENCY <br /> CITY NAME STATE ZI CODESITE PHONE N,WITH AREA CODE <br /> G d Y5 ' �O 2o9 --36 -35 S <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 PROCESSOR I ✓Box it INDIAN EPA ID N <br /> ❑ ❑ EKK TRUSTYLANDS dr ❑ U k P N of TANKS / <br /> 1 G0.R STATION [—]3FARM OTHER 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) PHONE H WITH AREA CODE <br /> Yllr Cr 2oq- -3525` L(Kd <br /> NIGHTS NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 10, 4r �' n/ (4&N <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ME As oV� <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> E S64AfVE <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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: 1. y 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 /> COUNTY# JURISDICTION K AGENCY# FACILITY ID If R of TANKS BI SITE <br /> 3 a 12= 101 1!) o <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1L L 5 7 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> I N14 <br /> LOCATIONNCODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Op L/ YES NO G <br /> LNECK# 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 INFORMATIONONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />