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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION O' o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P TLV CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 53 W <br /> 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAMES" <br /> / /�? (� CARE OF ADDRESS INFORMATION <br /> Y O ()D 44i <br /> ADDRESS NEAVST CROSS STREET ✓Ba vdcae ❑ PARTNOEMP ❑ STATE AGDKY <br /> ❑ MnON ❑ LOCK AGENCY ❑ FEODNL AGENCY <br /> EFF ❑ CNTv AGENCY <br /> CITY NAME STATE ZIP CODE _ SITE PHONE N.WITH AREA ODE <br /> 4o►L CA 9St.o S Zp _ �2/72 <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box it INDIAN EPA ID N X of TANK'E O <br /> ❑ 1 GAS STATION ❑3 FARM E] 5 OTHER TRUSTYLANDS ATION of ElAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> f"kKs Lam) C'm y32f Z �u.„.e <br /> NIGHTS' NAME(LAST,FI T) PHONE N WITH AREA CODE NIGHTS'. NAME(AST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS, <br /> LeEddre � 2/2 �t <br /> 11. PROPERTY OWNLtR INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME fes_- B ^ 1 CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS V ` 1 I ✓Bo intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE_ <br /> 21P CODE <br /> G PHONE N,WITH AREA CODE <br /> C70 <br /> s u�✓ _ 6 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Bo intlicale ❑ PARTNERSHIP 11STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.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. ❑ 11. 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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION# AGENCY# FACILITY ID R It of TANKS at SITE <br /> 101012 1171 10101010 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED Y NAPE PHONE N WITH AREA CODE <br /> PERMIT NUMBER YAt^V,`7PERMIT APPROVAL <br /> /DATE <br /> p py �PERMIT EXPIkATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUL#FILED DATE FILED <br /> D/ : 4-1 Z,0 YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST I1)OR MORE TANK PERMR FORM'B'APPLICATIONISI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> -W1 �i DATA PROCESSING COPY YI <br />