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STATE OF CALIFORNIA WATER RESOURCES CONTROIDARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS . Z <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE _ 1 O <br /> C9<iFO�N\P <br /> MARK ONLY ❑ 1 NEW PERMIT E] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7-EEBUAKNTLY CLOSED SITE <br /> ONE ITEM p INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE q ( 4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) __4 <br /> FACILITY/SITE NAME -/ CARE OF ADDRESS INFORMATION <br /> (ne v /TTf- p <br /> ADDRESS <br /> ®C/ A NEAREST CROSS STREET rl to 1 ❑ PARTNERSHIP LISTATE AGENCY <br /> D „ CORPORATION 11LOCAL-AGENCY ❑ FEDERAL- <br /> AGENCY <br /> 0 INDIVIDUAL Cl CCOUNIAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE <br /> S7oc(�w�✓ CA 9.5-7_4 6 zo — 2- q <br /> TYPE BUSINESS. F-] 2 DISTRIBUTOR I PROCESSOR ✓Box it INDIAN EPA ID # <br /> 1 GAS STATION �3 FARM E 5 OTHER TRUSTYATION LANDS or ❑ - #of TANK'S <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE it WITH AREA CODE DAYS NA E(OAST,FIRST) PHONE p WITH AREA CODE <br /> Al T<N/;2 at'a P''WINeZ 1'rc.,tz <br /> NIGHTS: NAME(LAST,FIRST) PHONEk WITH AREA CODE NIGHTS. NAME(LAST,FIR ) PHONEp WITH AREA CODE <br /> U w -6(6s--f Cl <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY 0 FEDERALAGENCY❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE q,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> G Fv2o,,J 4 - 9-2o33 D o CARE OF ADDRESS INFOFi�tAT10N <br /> r� 7iNEz <br /> MAILING or STREET ADDRESS xto Indicate ❑ PARTNERSHIP 0 STATEAGENCYO L CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> V ❑ INDIVIDUAL 0 COUNTY-AGENOV <br /> CITU NAME S—rT� STATE ZIP CODE Z O 6 PHONE 2V p,WITH AREA CODE <br /> (��' 3Y/6 Z !l4 <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. 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) PATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3g �] 0 b I l o o <br /> CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE#WITH AREA CODE <br /> G EY�LS'0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT <br /> J0 SUPERVISOR-DISTRICT <br /> -III`/S/'jTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> CHI AM CHI PERSURCHARGE AMOUNT FEE CODE VES RECEIPT if ❑ BY. QA <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 INFORMATION ONLY. <br /> FORM A(3-2-58) • <br /> DATA PROCESSING COPY <br />