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/ - - .F t� ,..��-- .,q,f.-sr.. .,rw'r- •- .y►' .s _ � .. .-.. -,warns-i•1•a-��.. —.i'�R`�°'gR <br /> STATE OF CALIFORA WATER RESOURCES CONTROBOARD ,�yEA aVor;'•T�F A. <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITIE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ta' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT LO'F5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY OSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �3 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) I O <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> mu L�t.R Su <br /> ADDR SS �f NEAREST CROSS STREET oindirate ❑ PARTNERSHIP ❑ UATE-AGENCY N <br /> CORPORATION C LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> liet �.,,) J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME r� STATCZ l cJ d{7 O I,S �N AREA CODE <br /> A <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR El4 P ESSOR ✓Bax if INDIAN EPA iD # <br /> RESERVATION or _�, p of TANK's <br /> ❑ 1 GAS STATION E] 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE Q <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 /> 1 e_r P Caog 3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Skey- a r0 ('- ';e_ <br /> MAILI G.,STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> © O CORPORATION C) LOCAL-AGENCY ElFEDERAL-AGENCYI 'fC] INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME Q STATE ZIP CODE PHONE#,WITH AREA CODE <br /> L o <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OFADDRESS INFORMATION <br /> MAILING Dr STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.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: 1. ❑ II. 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# #of TANKS at SITE <br /> = - I I E[ I / 1317-To-1 Fo-T 7o oLd <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> IM rrL ! 1 <br /> PERMIT NUMB R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION ODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O . YES ❑ NO �(/o/ff?y9Z. <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) - <br /> DATA PROCESSING COPY <br />