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STATE OF CALIFORN w _ <br /> /SEP\'uviv'�•?hE.. <br /> ATER RESOURCES CONTROL BOARD <br /> FORM 'A': ( ` <br /> UNDERGROUND STORAGE TANK PROGRAM D <br /> SITE 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 ❑ 7 PER LOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE w <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> SFIELL SERVICE 5-17A1100 <br /> ADDRESS NEAREST CROSS STREETe, <br /> cat, D PARTNERSHIP D STATE AGENCY <br /> ounilo" DourynEFEDERAL AGENCY <br /> 42b W. KET`17LEMAQ LA0E NLITGFIIN5 5T11pD LOCAL <br /> AGENCY <br /> CITY NAME STATE ZIP CODE ITE PHONE#,WITH AREA CODE <br /> LO DI CA 95240 2oq 334-0568 <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a #of TANK's <br /> ur1 GAS STATION ❑ 3 FARM 1:1 5OTHER RESERLANDS <br /> VATION or ❑ 6AG-00 05 573 AT THIS SITE 4 <br /> TRUSEMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST FIRST) HONE#WITH AREA CODE <br /> GALLOQA`( M IGNAEL (?Oq) 334-05(8 GaLLOwAY LDOL>O-fHY (204 -054 <br /> NIGHTSNAME(LAST FIRST RHODE 4`NITH AREA CODE NIGHTS- NAME(LASTFIRST) PHONE 4 WITH AREA CODE <br /> GALLOWAY, MIGNAEL (20V334-4523 GQLLOI.JAYpmzoTNY(209)543-63 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME W, <br /> ELIf wss-r1 ' 13AR13E." CARE OF ADDRESS INFORMATION <br /> MAILING DrOTREET ADDRESLS _7 2 ►7 ✓ x to intlicale D PARTNERSHIP ❑ STATE-AGENCY <br /> DO <br /> D OX / I /� CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> i ❑ , _l 153 INNDIVIDUAL D COUNTYAGENCY <br /> CITY NAM STATE ZIPD PHONE# WITH AREA CODE <br /> MMLE 6EAG <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME 45 N E L LDI L GO. CARE OF ADDRESS INFORMATION <br /> MAILING or TREET ADDRESS �I 1 /M�. xt°inD dicale PARTNERSHIP D STATE AGENCY <br /> 13 -/90 WILLOW PASS IZD.SUITE 1CORPORATION ElLOCAL-AGENCYD FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNn AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITHAREACODE <br /> Go1.IGoRp as 94 520 0415 X7&- A14 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS I��I <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ III.ISI <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 /> ALF2EP A. S?EWART 7• �.g <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> EEIZIY[K�l <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ECHECK# <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES -d''PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAS OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNIHHH�SS THIS IS A CHANGE OF SITE INFORMATI L F <br /> <'' <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />