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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD l' <br /> FORM `A': ` . . {m <br /> UNDERGROUND STORAGE TANK PROGRAM w b <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO -o' , o <br /> c COMPLETE THIS FORM FOR EACH FACILITY/SITE `'A�Fow•`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLYCLOSEDSITE F'+ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) QO <br /> co <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Af ("do if/wftz/D <br /> ADDRESS I NEAREST CROSS STREET �/(g-w_—b_itlirtle 11PMINIAS4IP ❑ STATE AGE) <br /> O yJ� r,KN AUR wTON ❑ U)CAASFNLY ❑ RDEAAIAGENC <br /> tel. LJ UUMWAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZlPrnnc <br /> SITE PHONE N.WITH AREA CODE <br /> ack N CA 957,03 _ -( <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER RESEr ITANK's <br /> TRUSTYLANDS ATION o ❑ (,I �,r) AT THIS SITE ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NA FI ST) PHONE N WITH AREA CODE DAYS: NAMF(LAST,FIRST) PHONE N WITH AREA CODE <br /> (Fred* 2b9 -,?Y - figs 08-RA/'7-01 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> LtK'`' LLN <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> AI rrr1 / /^to� A/da -do <br /> MAILINGar STREET ADDRESS ✓Boz to intlicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 23� C00 CORPORATION 0 LOCAL-AGENCY 1:1 FEDERAL-AGENCY <br /> INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME'90STATE CODE PHONE N,WITH AREA CODE <br /> A.; <br /> ZIP ose C>9 5/ZS 4'o8-2Y�7ror7 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Some As <br /> MAILING or STREET ADDRESS ✓Boz to indite 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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: 1. ❑ 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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION a AGENCY N FACILITY ID N x of TANKS at SITE <br /> 3 Oo 12-EHE 10 10 10 <br /> CURRENT LOCA^L ACY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> ��LGEN <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> NA <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTpR�ICT CODE BUSINESS PLAN FILED DATE FILED <br /> l 2MIT 0� �O YES NO ❑ l�///06 C'C_ <br /> CNECKN PERMIT AMO LINT SURCHARGE AMOUNT FEE CODE RECEIPTp 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. j <br /> FORM A(3-2-88) j <br /> "e DATA PROCESSING COPY ri/ � ... <br />