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STATE OF CALIFORNIS WATER RESOURCES CONTRO OARD <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM = � o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMAUUTIZ?LlOSER SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE b V -4 <br /> co <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> N <br /> FACILI ITE NAME ;-� 1 CARE OF ADDRESS INFORMATION <br /> im OVA RI!-.vm, i <br /> ADDRESS NEAREST ROSS STREET ✓Six, '6 1, '❑ PARTNERSHIP ❑ STATE AGENCY <br /> 1 . �( Wo <br /> t o ElLl CAAPOAATION ❑-LO ❑ FEREAAL AGENCY <br /> 5Ov) w <br /> N INDIVIDUALCOUNTY❑ AGENCY <br /> AGENCY <br /> CIN NAM STATE ZIP CODE SITE PI,HO1N N WITH AREA CODE <br /> p C�K40 V) CA N0 <br /> TYPE OF BUSINESS: ❑ @ DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # III of TANK's <br /> ^ ///1(//� 13 AT THIS SITE f <br /> ❑ i GASSTATION ❑ 3 FARM 5 OTHER TRUSRVIANDS or ❑ CH V M+ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIflST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Erlk Frye ri Zo�t <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME, 'L - "1/ sI- I'I va I ,xx CARE OF ADDRESS INFORMATION <br /> MAILING r ST ET AD RE V1 IR` L7l ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> }, LIQ ❑ CORPORATION Cl LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> l 1y' /�((d Or�I d Q T%IIINDIVIDUAL Cl COUNTY-AGENCY <br /> /� ��T/� /E(� '/�/L y/' <br /> CITU ryAN1E O { IV l Ste-" \; 1G P,0 \"(N'f W 1 6RlP COLE / (f <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 /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN 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 THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ' <br /> (CANT'S NAME(PRINT D&SIGNATURE) DATE <br /> ijrluvI A, &avV o <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION If AGENCY R FACILITY ID 1f R of TANKS at SITE <br /> 3 qI I I _�,-Is aI L9 10 1 o 1 i <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE <br /> SFW L4 9 <br /> PER7CODECENSUS <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOT A! SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL�E`JDD <br /> CHT SURCHARGE AMOUNT FEE CODE YES ❑RECEIPT YG ❑ BY: _ �_ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLIII THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> \ FORM A(3-2-88) • <br /> DATA PROCESSING COPY <br />