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STATE OF CALIFORNIA WATER RESOURCES CONTR6eBOARD <br /> 5E„l Ap <br /> w <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> S!T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> CCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY �-7�NEW PERMIT F-] ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM L9` INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE m Zr <br /> 1f� <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r ' <br /> ADDRESS w NEAREST CROSS STREET ✓Ew[ i,x sIs ❑ PARDUMIP ❑ STAHAGENCY <br /> 9911 ❑ CNYIDUk ON ❑ LOCAL-AGENCY ❑ FEOEAN.AGENCY <br /> /cSoI�I J/ O INNIVIGUAI ❑ c0uxrv.AGwcv <br /> CITY NAME -/_ _ STATEZIP CODE SITE PHONE 11,WITH AREA CODE <br /> __S DXY � CA a0 3 (aZb9 ! �o�o -34F1 <br /> TYPEOFBUSINESS: Ej2 DISTRIBUTOR F-1 4 ESSOR I/Box if INDIAN EPA ID N RESERVATIONT,, ,� If of TANK's <br /> ❑ 1 GASSTATION ❑3 FARM 6 OTHER TRUST LANDS Or ❑ / w AT THIS SITE pY— <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(RST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAM T, RST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 5aY)q e- cog 66-6/6S <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> me cis s � � e <br /> MAILING or STREET ADDRESS Box to inchoate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> O �i yl E e t 1?f.0 <br /> MAILING or STREET ADDRESS ✓Box to incicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> O 9 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMSTATE ZIP CODE PHONE p,WITH AREA CODE <br /> fOG how c� Sao Cao -369 <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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® 10101 / / 3 000 <br /> CURRENT LOCAL AOENCY FACILITY ID# APPROMED BY NAME PHONE#WITH AREA CODE <br /> 141 xgl�u a-.) <br /> PERMIT NUMBER PERMITAPPROVALDATE PERMIT EXPIRATION DATE <br /> S // <br /> LOCATION CODE CENSUS TRACT# 11PERVISOR-DISTRICT CODE BUSINESS PLAN FILEDDATE FILED <br /> en / 3. YES ❑ No <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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 ONL�,,,� <br /> SFORM A(3-2-SS) <br /> DATA PROCESSING COPY �� <br />