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STATE OF CALIFORNIR WATER RESOURCES CONTR BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ^�o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION<< I <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EX CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 7j � <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 01 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 4doch^WIRN Mt'C- LQ 56reAcP/J <br /> ADDRESS NEAREST GROSS ST EET ✓Em to ilbirak ❑ PAATNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION ❑ COUNTY <br /> YAGEN ❑ FEDERAL AGENCY <br /> ❑ INOIVICUAL ❑ couxnAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> SOC +01-) CA 5'330- 1;W ^09 -0/23 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR V4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'# <br /> RESERVATION or AT THIS SITE (//ry/{ <br /> E:] 1 GAS STATION ❑ 3 FARM E] 5 OTHER TRUST LANOS 1:1 /`� <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 /> $07csr e 2&I-9S3-UlA3 <br /> NIGHTS: NAME(LAST,FIR61) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> r(uc • e_ t1proj zo"�-SZ3-30hV <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 00( Mr6- Co Cci i S'cl^Pn� FAN <br /> MAILING or STREET ADDRESS ✓ ox la Intlic ,A ❑ PARTNERSHIP ❑ STATEAGENCY <br /> CORPORATION 0 LOCAL AGENCY 0 FEDERALAGENCY <br /> O Qx INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> o� 9.jd I <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e as <br /> MAILING or STREET ADDRESS ✓Box to iodoale 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 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: 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I id d I I 5= <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE p WITH AREA CODE <br /> oo <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 31 YES NO .�i6 99 <br /> CHECK# PERMIT AMOUNT SURCHARGEAMOMT FEE CODE RECEIPTp BY: <br /> C <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 /> - I FORM A(3-2-SBI •-_ <br /> DATA PROCESSING COPY <br />