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STATE OF CA " <br /> LIFO S <br /> FORM `A': IA WATER RESOURCES CON <br /> TROL BOARD <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PE wp <br /> RMIIT APPLICA <br /> COMPLETE THIS FORM FOR EACH AGILITY/51TE TION <br /> MARK ONLY I NEW PERMIT <br /> ONE ITEM 0 3 RENEWAL PERMIT e9`�fo ax�P <br /> 2 INTERIM PERMIT 5 CHANGE OF INFORMATION <br /> I. FACILITY/SI4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE 7 PERMANENTLY <br /> FORMATION &ADDRESS — SED slrE <br /> TE IN <br /> FACILITY/SITENA E (MUST BE COMPLETED) .p <br /> ADDRESSCARE OF ADDRESS INFORMATION <br /> S—A <br /> 1 <br /> �� `.J +`— NEAREST CROSS STREET { <br /> CITY NAME ✓&aloir,dicale ❑ Ai1RTN�€RSHIP (� <br /> � ,l l ❑ Ct7RPORATION ❑ I I-AGENC, ❑ FEUER AGENCY <br /> STATE ❑ INUi�'iGUAL �T-- ❑ �`Ef1ERd1-AGENCY <br /> ZIP CODE COUNTY-AGENCY <br /> TYPE OF BUSINESS. CA <br /> I GAS STATION SITE PHONE#.WfTH AREA CODE <br /> 2 DISTRIBUTORR 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> El 3 BOX <br /> or ❑ <br /> TER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) # THIS SI <br /> DAYS; NAME( ST,FIRST) EMERGENCY CONTACT PERSON AT THIS SITE <br /> _ PHONE#WITH AREA CODE �SECONDAAY) <br /> Ca Q yr DAYS NAME(LAST.FlRsr) <br /> NIGHTS: NAME(LAST,FI ST) `7 b 7,? PHONE#WITH AREA CODE <br /> S, e PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER IFJ9:FORMATION &ADD R1PHONE#WITH AREA CODE <br /> NAME SS (MUST BE COMPLETED) <br /> C k4m_]� CARE OF ADDRESS INFORMATION <br /> MAILING or STREET AIq 3aDDRESS <br /> ✓BOX to indicate ❑ PARTNERSHIP <br /> Cl CITY NAVr , El NDIVIDUALION ❑ LpC�at AGENCY ❑ FEDERAL-AGENCY <br /> AGENCY " <br /> STATE UNTY-AGENCY <br /> CZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION ADDRESS <br /> (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAELl.'.�_Y^AEET ADRESS <br /> ✓Box to indicate ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-STATE-AGAGENCY <br /> CITY•.ANE ❑ INDIVIDUAL ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> STATE ZIP CODE <br /> PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WIIMCS AN ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. <br /> II. ITL <br /> TN'f5 FARM HAS BEEN COMPLETEQJDER PENALTY OF PERJURY AND TO THE BEST OF MY KNOEl <br /> WLEDGE,IS TRUF AIV,p CORRECT <br /> APPLICANT'S NAME IPRIN7FO b SWURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION N AGENCY# OEFACILIT <br /> #of TANKS of SITE <br /> 1�a E= 4�9 ;�, q 4 0 <br /> LOCAL AGENCY FACILITY ID# 00 0 <br /> APPROVED BY NAME <br /> DC___) PHONE#WITH AREA CODE <br /> PERMIT NUMBER PIPPROVAL DATE <br /> PERMIT EXPIRATION GATE <br /> LOCATION DE CENSU TRACT M� SUPERVISOR-DIS RICT CODE BUSINESS PLAN FILED <br /> o�j DATE FI EU <br /> + YES NO <br /> CHECK# PERMIT AIIIOUNT SURCHARGE AMOUNT FEE CODE <br /> REGEIpT <br /> BY: <br /> THIS FORM MUST BE ACCOMPANIED BY Al OR MORE TANK PERMfT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />