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• • <br /> STATE OF CALIFOR�A• WATER RESOURCES CONTROL BOAHECEI <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM AUG 13 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPhf99NTAL <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> N <br /> MARK ONLY <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Sl l-�Qn jl rd �, 993� Q <br /> I-uCl 8 5 Z -fh�r T I 10 <br /> NEAREST CROSS STREET ✓ i¢le ❑ PAATNENSHIP ❑ STATEAGENIX <br /> ADD�E$S q T� CORPOflATION 0 LOCAL�AGENGY 0 FEDUKAGENCY <br /> ffVv� Gy. Q-�I r ❑ INDMWAL 0 COUNT AGENCY <br /> Jl. STATE ZI$CODE ITS PHONE X,WITH AREA C0 <br /> CITY NAME , (•'Tf`LJ�IJJ• -80915 <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID# k of TANK# <br /> ra e 3 <br /> ❑ ❑ RESERVATION OrAT THIS SITE <br /> GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ none-, <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE X WITH AREA COD <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(I-AST,FIRST) — <br /> V_ bon - 3 3 0 1' M (0 4 <br /> IG TS: NAME(LAST,FI ST)) w , + PHONE X WITH AREcq-,SPODE HTS: NAME( ST,FIRST <br /> PHONE q ITH A CODE <br /> II.ENAME <br /> ERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)E OF <br /> 7FRESS <br /> ftAIDDRIESS <br /> - m <br /> a indicate 0 PARTNERSHIP CSTATE-AGENCY <br /> rt , CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> r 0 INDIVIDUAL 0 COUNTY-AGENCY BTZCPONE WITH AREA COD <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)MATION <br /> NAME fin[_ yyx.e <br /> L T ✓B �/ i�odllic a ❑ PARTNERSHIP 0 STATE-AGENCY <br /> MAILING or STREET ADDRESS I ��. ORPORATION CLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C �� 0 INDIVIDUAL <br /> El COUNTY-AGENCY <br /> J STATE ZIP CODE P ONE X, ITH AREA CODE�� I <br /> CTY1NAMEN •L�+^~J 'C 2 <br /> l ' L <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. 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND 8CORRECT. <br /> � DATE <br /> APPLICANT'S NAME(PRINTED 8, TORE) i Lb IU 11"ll <br /> LOCAL AGENCY USE ONLY /v <br /> COUNTY k I�JURISDICTION k AGENCY k FACILITY ID k k of TANKS at SITE <br /> m Icy <br /> CURRENT LOCAL AGENCY FACILITY ID X <br /> APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> DATE FILED <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS IES N FILED NO <br /> CHECK X PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE- MORE TANK PERMIT FORM 'B'APPLICATION( kit THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />