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10 <br /> STATE OF CALIFORNI WATER RESOURCES CONTROL—BOARD <br /> FORM `A': = <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE - FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> S <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C��F�RN\P <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I"a <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �� <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUS BE COMPLETED) <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Louli�s [Y)0,( r-) Lout � 11 CifI, <br /> ADDRESS ,, ` NEAREST CROSS STREET ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> 1 Sc, ❑ INDIVIDUALIDN ❑ COUNTY-AGENCY LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> 'S+0Ck jz CA G�j:Z I .�c� 9 L41 i5 <br /> TYPE OF BUSINESS: IJ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> RESE <br /> ❑ 1 GAS STATION ❑ 3 FARM El5 OTHER TRUSTVATION LANDS or AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COD NIGHTS: NAME(LAST,FIR$= PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> L-v u ia c,1 i il_c( f)l o L <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> G" _ C,� RPPRATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> U, �X'�,,V INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ST ZIP CODEPHONE#,WITH AREA CODE <br /> C, C 15 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> U_C,QRP <br /> ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 10 INDIVIDUAL ❑ 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 /> Ea 6 [ r c", <br /> CURRENT LOCAL AGENCY F�CILITY ID# � � PPROVED BY NAME PHONE#WITH AREA CODE <br /> I I <br /> PERMIT NUMBE,,R/�`/�, `l'J� J��( PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-D STRICT CODE BUSINESS PLAN FILED DATE FILED <br /> LJ p <br /> ® -A - l YES ❑ NO ❑ L Z G G <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> I - - I <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 0 Y. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />