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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE [fl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PE NENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I O <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACI /SITS NAME CARE Of ADDRESS INFORMATION <br /> t4.+a..G..uv i/a ry <br /> ADDRESSy( / y� N ST CRaOSS STREET ✓Boxb Whale El PARTNERSHIP ElSTATE AGENU a) <br /> lJ� t4% 456% ❑ IND <br /> CITY <br /> ❑ W lv-AG C 13 �LAGENCY <br /> CITU NA STATE ZIP E ITEDPHON�p,WITH Q'f`A Eli <br /> 7-) <br /> 1 <br /> TYPE OF BUSINESS: F-12 DISTRIBUTOR Rr4 PROCESSOR ✓Box it INDIAN EPA 10 a (fT <br /> RESERVATION or /� #oI TANK's <br /> ❑ I GASSTATION [:] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ N A AT THIS SITE D <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.F STI PH NE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a ITH AREA CODE <br /> b Z YT- 77� -ti5 A 5104 <br /> NIG NAME IRST) NEa WITH AREA CODE NIGH E(LAST,FIRST) PHONEp ITH AREA CODE <br /> A y - r �' �i� SA <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CA;V/KESS INFORMATION <br /> is I—A <br /> ILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 3 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ ER AGENCY <br /> El INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE ONE a, ITH AAREA CODE <br /> oC C� SLDC 2m°► ( �T-����J <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF A DRESS INFORMATION <br /> _ ti N �% <br /> MAILIN or STREET ADORES -.1 SP.Loindlcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> x 41 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDER -AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY N41ME 1 V „ STATE ZIP CODE PHONE a, ITH 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. ❑ IL 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 It It o1 TANKS at SITE <br /> U 1 of U © o 10 11 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PCIE�C'KT <br /> ODE CENSUS TRACT* SUPERV SOR-DISTRICT CODE BUSINESS PLAN FILED DAT FIL 6R/ <br /> YES NO.70 <br /> O V <br /> 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 ONLY. <br /> FORMA(3-2-88) <br /> ♦/ DATA PROCESSING COPY <br /> L � _ <br />