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STATE OF CALIFORNIA* WATER RESOURCESCONTROLARD <br /> FORM `A': V <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / o <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE "'F=AA=" <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT P1 5 CHANGE OF INFORMATION 7 P TLV CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) GJ1 <br /> i� <br /> FACILITY/SITE NAME �, CARE OF ADDRESS INFORMATION <br /> �✓vc�L <br /> ADDRESS NEAREST C 0aq STREET <br /> ✓ to edirak ❑ PARTNERSHIP ❑ STATE AGENCY <br /> rY �� / �/ Lf$ I ❑ DDUALION Cl[I COUNTY AGENCY <br /> AGENCY fEOEItALAGENGY <br /> CIN NAME (J /(/ V DG / STAT^A ZIP CODE SITE PHOJ pA �i'A C DE <br /> TYPE OF BUSINESS' ❑ p DISTRIBUIOfl OCESSOR I/Box if INDIAN EPA ID a 9 B�of TAN7uK's <br /> RESERVATION or <br /> ❑ i GASSTATION ❑ 3 FARM E OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAS .FIRST) PHONE 0 WITH AREA CODE DAYS. NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> lyC��Fee CA er� � 367 <br /> e,NIGHTS: NAME(LAST,FIRST) 1 11 PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE d WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> � a5 <br /> ISI MAILING ar STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME ,� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE b,WITH 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. it. ❑ 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 A JURISDICTION# AGENCY# FACILITY ID Of #of TANKS at SITE <br /> CURRENT LOCAL AGENCY BACpTY 10 k _ /� APPROVED BY NAME PHONE Ar WITH AREA CODE <br /> PERMIT NUMBER ////N 7ERMIVITT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT,# SUPERVISOR-DISTRICT CODE BUSINESS EPLAN FILED NO ❑ DATE FILED --a fir <br /> K0 Ll 20 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FODE <br /> EE CRECEIPT# 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 />