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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' /40 <br /> �1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "'�P-"-''"• <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT D-5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT / AMENDED PERMIT -❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CAPE OF ADDRESS INFORMATION <br /> qWj5— 4 <br /> DU . <br /> ADDRESS NEAREST CROSS STREET ✓Bu b roma ❑ PAIRNISIYP 0 STATEASEKY <br /> 0UWVIMI16N 0 EUXAGExa 0 FEUEAaAU0 <br /> 0 uavnuu 0 caNn PCRICY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> __rfbel ar.L CA ysao ) 1165 -6 3 2-3 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 1 PROCESSOR ✓BOM A INDIAN EPA ID M <br /> ❑ 1 GAS STATION ❑3 FARM Q3"OTHER RESERVUNON or ❑ I of TANK'a <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(UST.FIRST) r PHONE P WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> �n1X1 � o �Oq) 1F65-6323 <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(UST.FIRST) PHONE M WITH AREA CODE <br /> (OP-1) qh - u-2 5 <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAJUNG a STREET ADDRESS ✓Ba to iwx;ale 0 PARTNERSHIP 0 STATE-AGENCY <br /> �/G ❑ CORPORATION 11LOCAL-AGENCY ClFEDERAL-AGENCY <br /> / 11INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP COO PHONE Y,WITH AREA CODE <br /> /18CIAOti 1 -7 9z'& <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS I*OHMATION <br /> �oa�`# 6te�G EG.G65ot� <br /> MAI STREET ADDRESS ✓Bto uxx"M 11 PARTNERSHIP 0 STATE-AGENCY <br /> �a s5 oa❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> �r't IsvAcy-t 4Y4Zr� <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ IL III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPUCANT'S NAME(PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY E JURISDICTION E AGENCY B FACILITY ID R E of TANKS BI SITE <br /> 3 a = = 1 1) 1 C) l 13e7( ,f�> 1 D 1 D l <br /> CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME mom It WITH AREA CODE <br /> GE Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATNNI CODE CEPMUS TRACT a SUPEIIYISOR-DISTRICT CODE BUSINESS RAN FILED DATE Fy�D <br /> D 7-3-$0 323 YES ❑ No ❑ -3('7Q( <br /> CNECKF PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIITF BY: <br /> THIS FORM MUST BE ACCOWANIED BY AT LEAF 19R MORE TANK PERMIT FORM 'S'APPLICATION($), ' ;S THIS IS A CHANGE OF SITE INFORMATION ONLY. • �- <br /> �r <br />