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STATE OF CALIFORA WATER RESOURCES CONTRO BOARD <br /> x : <br /> F RM A : UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION " p <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `�•o �." <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONSITE PERMA TLV CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE1531 <br /> .7 <br /> I. FACILITY/SITE INFORMATIONI& ADDRESS — (MUST BE COMPLETED) 10 <br /> FACILIT ;TE NAME FIIrli CARE OF ADDRESS I N FO RMATI ON <br /> O <br /> ADDY NEAREST CROSS STREET aHdote ❑ PARTNERSHIP ❑� Si�rEAGENCY N <br /> reS Co C �' P ❑ wowloun�IGN 1-1 <br /> counn cENCY L�NfoEaAt AGE1ra co <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH ARE CODE (� <br /> F,YUG CNVII CA <br /> TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCES90P ✓Box if INDIAN EPA ID n �I',` - <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUST RESERLANDS or ❑ /y ✓t'L�C� #01 HIS SITE AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -mimIkor, GorV D. ala a - <br /> NIGHTS: NAME(AST,FIRV PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Fe de l A oia-f)on /�cl►u�h iSt�u75`ary GAR L [). T'/4 I L• o✓' <br /> MAIAON TREET DRESS �/� /,/ xto lnd,oale ❑ PARTNE HIP ❑ S TE-AGENCY <br /> L!� DO� "�/ ✓✓ p OND0RATION ❑ LOCAL-AGENCY 1VEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If ATH AREA CODE <br /> k.OS /fin ekes C ODD 13 - 1191 <br /> III. TANK OWNER MWORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> Box to lndicale ElPARTNERSHIP 11 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE P HONE#,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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #o/TANKS at SITE <br /> = = = 017 / l 000 �0 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Sc < Vool <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT## SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE�FIILED p[7 <br /> 9 a 31 CJ CTt/ O� YES NO ElO C1 <br /> CHECK Of PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> aaaaaaar <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 /> FORM A(3-2-88) <br /> 0 DATA PROCESSING COPY 0 <br />