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STATE OF CALIFORNIAO WATER RESOURCES CONTROROARD <br /> W, <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE /e7 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO t o <br /> L=� COMPLETE THIS FORM FOR EACH FA /SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EK CHANGE OF INFORMATION ❑ 7 PERMANE D SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE y 8 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> (J^ f!S ' <br /> ADDRESS NEAREST CROSS STREET ✓B.ID Mule 11 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION Cl LOCAL IllFEOEMLAGENCY <br /> � <br /> 0 C `uL "/, ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA 3 60,? 3S- 30� <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTA OCESSOR ✓Boz if INDIAN EPA ID a /,/� <br /> ❑ 1 GAS STATION ❑ 3FAflM It of TANK's <br /> 50THEfl TRUSRESETATION LANDS <br /> or El AT AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> m . /�77e" 7YY- 77 -S/s/ <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE k WITH AREA CODE <br /> 261 we Laei- F,? -3 -a3/o <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S -s <br /> MAILING or STREET ADDRESS �saslea y, oA.,d�(� Er✓A0lrt_o,rxJicaHe 0 PARTNERSHIP El STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE y G/ PHONE�ITH AREA S--6 <br /> E232= � 3U� <br /> V] <br /> III. TANK OWNER INFORMA ON &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S A <br /> MAILING or STREET ADDRESS ✓Box lo,nd,cYle 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. 10, 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYIN JURISDICTION K AGENCY R FACILITY ID K K of TANKS at SITE <br /> 3 9 1D 10 / 1= D D 1C9 1 o <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE <br /> La vR19 ID <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 67-300© 3 ac/ YES ❑ NO ❑ <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If 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 />,. <br /> FORM A(3-2-88) . 0 <br /> DATA PROCESSING COPY <br />