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Y o <br /> STATE OF CALIFORNIA- WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM , <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m.I <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 1 O <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> i r ro <br /> ADDRESS QQ NEAREST CROSS STREET ✓COFFORATIO 0 PAIT�MWfA-AGS 0 STATE FEDEMGEO 00 <br /> lN Gr Q V ❑ INONIWALION ❑ L UNTYAGRI ❑ FEDER4LdSENLY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> K f 17w CA (�L 6 TV et- 7 3O' <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box R INDIAN EPA ID N <br /> RESERVATION or #of TANK's <br /> ❑ 1 GAS STATION ❑3 FARM .I OTHER TRUST LANDS ❑ /r"' ""' AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(EAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> AdQmso,,% Leorw (acq) v*-3738' <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Su m e CIAO 31tf-512ov <br /> II. PROPERTY OWNER INFORMATION &ADDRESS -(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> San J-o Q rL Cocvn-f <br /> MAILING or STREET ADDRESS JBON to Indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ,, / ./� ❑ CORPORATION W0 _9CAL-AGENCY 0 FEDERAL-AGENCY <br /> N VV L L� F �. 0 INDIVIDUAL W-COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE#,WITH AREA CODE <br /> �f o r✓� C4 1 4 ao �a_ <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> er <br /> MAILING or STREET ADDRESS J Box to IrMicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(4)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. X IN.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# MDI TANKS at SITE <br /> OD ! So DDD <br /> CURRENTAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER 3 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSUSTRA(C`TT* SUPERVISOR-DISTRICTC DE BUSINESS PLAN FILED DATE FILED /yyp_ <br /> / o 3. D {J ;.f+w- YES ❑ No ❑ $ a a $6 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(ILOR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-88) <br /> �-.r DATA PROCESSING COPY �� <br />