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STATE OF CALIFORNIT WATER RESOURCES CONTROL BOARD J <br /> �SE'`au��ii�tif <br /> Y <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ro" Z <br /> SITE O I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 90 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT PY'5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FA ILITY/SITE NAME CARE ADDRESS INFORMATION <br /> f A..A l�(� ; ,4 <br /> ADDRESS / .f. nom/ NEAREST CROSS STREET <br /> /�)O-P�oS7� ��'✓w""'Oy�P �a1l, ��/) I d 11 PARTNERSHIP ❑ STATE AGENLyCOApPOATION 11 LG4lAGENCY ❑ FEDEIALAGENCAQM <br /> ❑ COUNTY AGENCY <br /> CITY N E STATE ZIP CODE SITE PHGt4E ft,WITH AREA CODE <br /> CA �'J`2� b 70 P -3 to <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID <br /> If of TANII <br /> 1 GAS STATIONATION a <br /> ❑ [:] 3 FARM OTHER <br /> TRUSTTVLANDSdr ❑ t0 ATTHISSITE 0a <br /> RESREMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST PHONE#WITH AREA CODE DAYS: NAM (LAST,FIRST) PHONE a WITH AREA CODE <br /> mixii1 d rov e�9 $8 3 g 0� s S A <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS JN ME(LAST,FIRST) PHONE a WITH AREA CODE <br /> A SR �� . <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF DDRESS INFORMATION <br /> SRI "/A <br /> MAILING or STREET ADDRESS �x to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �1 M CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> (� 1 `- ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CI NAIESTATE ZIP CODE HONE N WITH AREA CODE <br /> (J,S,� C& ''S -z 36 zoo, Pd 7-3 p03 <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 51A lxhAiii <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If 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 k JURISDICTION k AGENCY# FACILITY ID a R of TANKS at SITE <br /> 10 1 C) ( 1 ,/) Io 16 16 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE a WITH AREA CODE <br /> 14 / <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACpT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0 YES <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 /> FORM A(3-2-88) <br /> 0 DATA PROCESSING COPY 9 <br />