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{ <br /> STATE OF CALIFORNIA WATER RESOURCES CONT06L BOARD <br /> J <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION I`o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ EW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION LXERYfNENTLYCLOSEDSITE <br /> ONE ITEM2 INTERIM PERMIT ❑0 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE 6 ��,y <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACIUTY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET <br /> i M� STATE AGDO/ /� Ald L0gIrcRATON aLM: <br /> ❑ FETIEPAL.AGDO <br /> CITY NAME ��/��,// STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> cA S'Zo 0 Z�09fir <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 ESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION or N of TANn <br /> ❑ T GASSTATION E]3 FARM OTHER TRUST LANDS ElAT THIS BITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS NUE(LAST,FIRST) PHONE#WITH AREA CODE <br /> m0t4 Reb /Or <br /> c�f.,2_ Zo9 F <br /> NIGHTS: NAME(UST,FIRST PHONE N WITH AREA CODE NIGHTS: NAM (LAST,FIRST) PHONEp ITHAREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME G • oS CARE OF ADDRESS INFORMATION <br /> _ <br /> MAILING or STREET ADDRESS /� ✓Box to indicate RTNERSHIP ❑ STATE-AGENCY <br /> N. <br /> /I ,/ / /O ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCV <br /> '] �Y Pj G� /✓ ///����^"""^�w' ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> �✓ - -1 Sr20 2 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> as � <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ 11. Ill.❑ <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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R AGENCY k FACILITY ID M k of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> At 17l•��2 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> /2 2,91046 <br /> LOCATION CODE CENSUS TRACT It SUPERVISOR-DIS ICT CODE BUSINESS PIAN FILED DATE FILED <br /> O ( YES NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> I <br /> 111 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISACHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-SB) <br /> DATA PROCESSING COPY 1"001 <br /> I <br />