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6 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =� o Z <br /> SITE� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION f o <br /> 1 " COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION JZ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE r O CD <br /> A <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) —1 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Te>J�o I Tar e N CAI - MaN+A {T <br /> ADDRESS NEAREST CROSS STREET ✓3NbiaNae ❑ PARTNERSHIP ❑ STATEAGENCY <br /> C'ITerokee ❑ CORPOMTON ❑ LOCALAGFNCP [I RDEIALAGENCY <br /> 33 55 c( Arf- (Z ❑ INDMDUAL ❑ CCLN7Y AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> %4d':.k-FD...J CA g5:2o5 204 9-31 -4750 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N a of TANK's 2 <br /> F-11 GASSTATION ❑ 3FARM © 5OTHER TRUST LAION or ❑ (A kooAtiN ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> dei w 20 - 1-6 SU U�kAXYLN, -_ _ <br /> NIGHTS: NAME(LAST.FIRST) PHONE If WITH AREA CODE NIGHTS. NAMF n AST FIRST) rNUNE N WITH AREA CODE <br /> e ( fJ 20-1 - 197-9-903 Ul-kul^"'A, <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE CO(IIIPLETED) <br /> NAME CARE OF Ar ORES.S INFORMATION <br /> -Te_f'jco -T' a- of TI.�C _ Ke" Madre <br /> MAILING or STREET ADDRESS 1'CORPORATION 11Box to indicate 11 LOCAL AGENCY 13FEDERA NERSHIP El AG ENCORPORATION DY X ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY N E1 STATE ,} IPZIPCODEE PHONE#,WITH AREA CODE <br /> rN 1 6 ey ?S613 U NkNOV.N <br /> _raWIII. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME 1 T CARE OF ADDRESS INFORMATION <br /> QNGO TfttC�-Ot y."NC (AivkflaA J <br /> MAILING or STREET ADDRESS V ✓So.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> P. eD X S�I" ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> SoLc raw elNj+0 CA Q ss 13 1 pq) 9F3 : <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ASOVS ADMISS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 0' 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 B JURISDICTION a AGENCY R FACILITY ID k a of TANKS at SITE <br /> T = = 10v1 1= 1 oob 124 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> ed <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> E CENSUS TRACT N SUPE SOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED ^p <br /> G !' YES ❑ NO I t ( a 0 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEECODE 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 INFORMATI4ONLY. <br /> FORM A(3-2-85) <br /> DATA PROCESSING COPY <br />