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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD z` <br /> FORM ' <br /> A':A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION IZO <br /> ,= COMPLETE THIS FORM FOR EACH FACILITY/SITE .oax`r <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE a 4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 <br /> FACILITY/SITE N E Alt- <br /> ADORE <br /> I /f CARE OF ADDRESS INFORMATION I /\ <br /> f CC '�' Alt- <br /> ADORE58 NEARE TC14OSS STREET GmlbiMc#e 0 PARMEARNP 0 STATE.AGEN(.Y <br /> ISO �Ne N ❑ LGcu AcM 0 RXIIAL AGDAN <br /> ❑ IImMWAL ❑ OWMAGENCY <br /> CITY NAME STATE ZIP CODE ITE PH NE#,WITM AREA CODE <br /> S-4dc�bf.) CA .z OS Zcq yig - <br /> TYPE OF BUSINESS: ❑ p DISTRIBLROR ❑ 4 PROCESSOR ✓Box ii INDTIOIAN EPA ID N <br /> ❑ I GAS STATION ❑ 3 FARM �OTHER TRUSTYLANDS or ❑ N AT THIS SITE <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 /> S I � ur 2 - 66 -141341 el K <br /> NICGH`TS'. NAME)LAST, RST) PHONE#WITH AREA CODE NIGHTS. <br /> NAME LAST, <br /> (LAST,FIRST) PHONE N WITH AREA CODE <br /> �nl ct UK-m <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SAME As = (/Iblct2 <br /> MAILING or STREET ADDRESS ✓Box loindicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION` <br /> urd SMr�(1 a Sh, r7% <br /> MAILING or STREETADDRE53 z ✓Dox to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Pp D,x f7J Q "CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> . V S 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE HONE,#,.WITH AREA CODE <br /> dN —Adq LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ 1015- <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# JURISDICTION# AGENCYIN FACILITY ID# ` #of TAANKS at SITE <br /> D 0 fl F 10101 O <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Shl QTY// <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE FILED <br /> YES NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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(3-2-68) <br /> \� DATA PROCESSING COPY `/ ( ' <br />