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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> yeP` T�f <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SIT!,,, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY/-l'_0 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM� E]2 INTERIM PERMIT ❑ 4 AMENDED PERMIT - ❑ 6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ° <br /> FA ITV/SITE NAME E OF ADDRESS NFORMATION <br /> V+ "A/ �i9n1� <br /> ADDRESS NEAREST CROSS STR ET ✓SoeN eiCcele PARTNERSHIP ❑ STATE AGENCY N <br /> CA <br /> / LlCORPORATION ElLOCAL AGENCY ElFIDER"AGENM <br /> 'V ❑ INONIOUAL ❑ COUNTY AGENCY <br /> CITY NAME �� STATE CODE SITE PH E p,WITH AREA CODE <br /> CA <br /> 953�(o y_ <br /> F BUSINESS ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Baz it INDIAN EPA ID p <br /> I GA�TA IT ON ❑ 3 FARM ❑ 5 OTHER TRUST ATION Gr ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> �F/� �i9 53 2 Ao/ 6 1— D <br /> GHTS'. NAME(LAST,FIRST) HONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHON WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CA OF ADDRESS INFORMATION <br /> 3 <br /> MAILING or STREET ADDRESS ✓Bax to indicale PARTNERSHIP 11STATE-AGENCY <br /> /fir CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> yn Z� <br /> U J 6CJ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> C AME TATE ZIP CODE P E p,WITH AREA CODE <br /> 9 <br /> C;0- <br /> Ill. <br /> 3?D �` 9 2 6?9 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MA G or STREET ADDRESS ✓Box to indicate El PARTNERSHIP 11STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY AME STATE ZIP CODE PHONE p.WITH AREA CODE <br /> IV. EGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. Be 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 /> 31 OUNTY R JURISDICTION R AGENCY# 3 FACILITY IDIf of TANKS at SITE <br /> CWlfk*T LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 6,7-1 VIg0 i 10 <br /> PERMIT NUMBER PERMIT APPROVAL DATE y� PERMIT EXPIRATION DATE <br /> T <br /> 03NCODE USTRACTN ERVISOR-D�RICT CODE BUSINESSPUN FILED NO <br /> ❑ FIL D <br /> LCH, <br /> CK N ERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY kJ <br /> S <br />