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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> t f <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM _ o <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C O P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 EW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDSITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Vallev6VA,alesaZe L16 <br /> ADDRESS NEAREST CROSSTREET ✓ mcc ❑ PAR711 0 AGEN na <br /> ION 0FMA19 N• — k'✓GE3 "DMDUAL0 CONN GFGN <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE „ ► , <br /> Vn CA 5A0 Cao9 (o(v-0 13 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 P SSOR RESERVATIONxit INDIAN <br /> or EPA ID It p M a TANK's <br /> ❑ I GAS STATION E] 3 FARM OTHER TRUST LANDS Elt'✓ �/ TL e AT TRIS 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 /> Shad ✓e Cao �iGG-D 3 <br /> NIGHTS: NAME(LAST,FIRSTJ ITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> sa yn f- a. <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME J LO Yu Shane-Pf CARE OF ADDRESS INFORMATION <br /> MIT STREET ADORESS V ✓fix to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> �/ CORPORATION D LGCAL-AGENCY 0 FEDERAL-AGENCY <br /> "�r Fr 0 INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ' ZIPCO�O PHONE#,WITH AREA CODE <br /> P CODE <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) , <br /> NAME CARE OF ADDRESS INFORMATION <br /> >; R S Owner <br /> MAILING or STREET ADDRESS ✓Sox to indicate 0 PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE C WITH AREA CODE <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. X 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY V FACILITY ID# #o1 TANKS at SITE <br /> 101(91 /= e o0 <br /> CURRENT LQCAL AOENCY FACILITY ID k APPROVED BY NAME PHONE M WITH AREA CODE <br /> u I <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEN'S7US TRACT M!!,, SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O 1 rT <br /> 3. 9-o j U YES NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGEAMOU MIT FEE CODE RECEIPTa 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 /> \\`TVsV1l DATA PROCESSING COPY 1 <br />