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STATE OF CALIFORNIA WATER RESOURCESCONTROROARD iz <br /> FORM `A': � `•A <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION IZ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT4 AMENDED PERMIT <br /> ❑ ❑6 TEMPORARY SITE CLOSURE / <br /> CID <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) C" <br /> FACILRY/SITE NAME CARE OF ADDRESS INFORMATION <br /> n1roci- i <br /> ADDRE�SJS[� N REST C OSS STREET <br /> ^ / Q �-, ,, Q ❑ COPPoRATION ❑ PARTNERSHIP <br /> ❑ FEpEgA TATE AGENCY <br /> CITY NayeE °'`�"'�- �u'�-�''--' ❑ INomowL ❑ COUNTYAGENCY Lu K <br /> STATE ZIP CODE /T SITE PHONE#,WITH AREA CODE <br /> TYPE of BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓ CA ����✓ �� _3� <br /> ❑ ❑ Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION ❑ 3 FARM ®5 OTHER RESERVATION or ❑ #of TANK's <br /> CqTRUST LANDS None, AT 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 ft WITH AREA CODE <br /> MCAA_r ee- d doq 369-36 // <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST FIRST) PHONE p WITH AREA CODE <br /> 09 3E,9 -161S / <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING+or STREET,ADDRESS % ✓Box toindicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> SI \N) - L�`45 13 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERA -AGENCY <br /> FI INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> Lo d I C/4 19 5.n I I if A n <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAM,EEK 1 CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> V v L V,Ca S Cl CORPORATION ❑ LOCAL-AGENCY ❑ F�DERA -AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCYL�, <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Lo dL CA 9say0 aov <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. ❑ if. ® 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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION K AGENCY R FACILITY ID N #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN �noox"•�n'-- '- PHONE N WITH AREA CODE <br /> laiD 4a <br /> PERMIT NUMBER PERMIT APPROVAL DATEPERER - —AT <br /> MIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> j <br /> JS�• <br /> CHECK YES E] NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT 7EECODE 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 />