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140)4*- 179 - /(PC - 40 C&n 111441c to <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM °° <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION _m o <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMI7 5 CHANGE OF INFORMATION ❑ 7 PERNPWNTLYCLOSEDSITE I"A' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE - <br /> Lq <br /> CID <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAMEp CARE OF ADDRESS INFORMATION <br /> Akdowrl Rob Its $-{eve- ie <br /> ADDRESS NEAREST CROSS STREET ✓C/JIPDMTIDN ❑ LDGL-ATfXLY11 w ❑11 sTATEAGeeLY III <br /> r• `❑ INDmouu ❑ cwm-K cy <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> NZ <br /> " CA 17gao 5 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓13Ox R INDIAN EPA ID# Not TANK's <br /> ❑ 1 GAS STATION ❑3 FARM �5 OTHER TRUST ATILANDS <br /> or ❑ <br /> RESER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA ODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAME - .S CARE OF ADDRESS INFORMATION <br /> MAILING or STREET <br /> AAAD7OREES$a�^/1I, ,, ''.. 11 /� ✓ xto intlicate ❑ PARTNERSHIP ❑ STATE-AGENCYVroI <br /> I49 Lu W Av ❑ NDIIVIDUALION ❑ OUNTYAGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE#,WITH AREA ODE <br /> SAA 1 CA <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> o 120 <br /> MAILING or STREET ADDRESS ✓ indicate 13 PARTNERSHIP ClSTATE-AGENCY <br /> //�� CORPORATION ❑ LOCAL-AGENCY 13FEDERAL-AGENCY <br /> V o 5543 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME �/ y STATE - ZIP CODE PHONE#,WITH AREA CODE <br /> S l ce'k-�'J�{V ^�' <br /> N <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 /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# It of TANKS at SITE <br /> m I I 1 alilil <br /> CURRENT LOCAL AGENCY FACILITY ID Is APPROVED BY NAME PHONE#WITH AREA CODE <br /> 3`-k- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DI—SfTIIICT COD! BUSINESS PIAN FILED DATE FILED <br /> CI 2— • L / 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($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> ,'� DATA PROCESSING COPY <br />