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/!` l—o'J <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A : UNDERGROUND STORAGE TANK PROGRAM 0�� mo <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH F CILITY/SITE `'"'OR <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT Y CLOSED SITE z <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE #p <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> FACSl�'/SITE NAME CARE OF ADDRESS INFORMATION <br /> N t` elJ <br /> ADDRESS NEAREST CROSS STREET ✓Ea Nmve, O PARTNERSHIP O STATE AGENCY <br /> (f x S I. O CORP TON O LOCAL-AGDO O RDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNT AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS'. EPA ID # <br /> 2 DISTRIRUIOfl U4;,PR ESSOfl ✓Box if INDIAN <br /> RESERVATION or #of TANKY <br /> ❑ 1 GAS STATION ❑ 3 FARM <br /> OT" <br /> TRUST LANDS ❑ AT TNISSI% <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 /> kpmFgs ly x'23 -,5225 1y1c DN � 20V <br /> NIGHTS: NAME(LAS FIRST) PHONE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> 6ir C CONWi CC-wr .e03- 77-1'7 Mam 1 ICe7u/ 209> qe3 - G27�L <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> PIilnr, c, bEa <br /> MAILING or STREET ADDRESS ({�1 �A]],�.,.�� LL ,rl✓, to indicate O PARTNERSHIP O STATE-AGENCY <br /> C IIV W/7/Y7I U0�'1 Zr/�"Ja LJ INDIIVIDUALION 0 LOCAL-AGENCY El 0 COUNTY-AGENCY <br /> FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ,WITH AREA CODE <br /> S Rmpn/ C// 99-5003 /5� Z3- ;-1 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> LL <br /> MAILING or STREET ADDRESS Y–,Qcxto indicate O PARTNERSHIP O STATE-AGENCY <br /> Lff VSs � - 9-ol , 2 3 C ❑ INDIVIDUAL D COUNTY-AGENCY AGENCY GENCY D FEDERAL-AGENCY <br /> V <br /> CITY NAME STATE ZIP CODE PH NE If WITH AREA CODE <br /> pp-8s C 702 /-1/5 23- 87 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 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# If of TANKS at SITE <br /> 0QO / <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA N CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO Ej /,,,/d7/9 <br /> CK* PERMIT AMOUNT SURCHWiDE AMOUNT FEE CODE RECEIPT# by: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASTA)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 5 <br /> FORM A(3-2-SS) / – - -- <br /> DATA PROCESSING COPY \ai � <br />