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STATE OF CALIFORNIV WATER RESOURCES CONTRONOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM 1 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; o <br /> 31- COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 50 <br /> MARK ONLY ❑ 1 NEW PERMIT E] 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION �eT7 PER <br /> CLOSED SITE I"a <br /> ONE ITEM 2 INTERIM PERMIT q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> co <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) rn <br /> FA ITY/SITE NAME CARE OF ADDRESS INFORMATKobiurfpr <br /> (nonc�aut I ner GIL C*C''&X" <br /> ADDRESS NEAREST CROSS STREET ✓ <br /> SgSll _ 11IP, 'ale Cl LOCALPARTNGEN 0 STATEAAGEN <br /> ' %>11 P, ❑ LDGL-AGENCY ❑ FEDEHALAGENW <br /> Cliiyy��!lAME ❑ INDIVIDUAL 0 COUNTY'-AGENCY <br /> / \ � V ('J R�V STATE ZIP�ODE SITE PHONE k,WITH AREA CODE <br /> rl -f CA 5 0 3l0 <br /> TYPE OF BUSINESS'. L_j p DISTRIBUTOR q PROCESSOR ✓Be,i1'IN EPA ID a <br /> 1 GAS STATION �3 FARM �.11THER RESERVATION Or ❑ - #of TANK'# v <br /> TRUST LANDS 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) <br /> PHONE#WITH AREA CODE <br /> Q1' f_f. ' C tr (:xn2.a 9 3(09* Pc�� M do 'J ( SS 1345 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> P-oy-\ M jxn 3 3-1 It <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME Q CARE OF ADDRESS INFORMATION <br /> l 1on <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP <br /> El❑ CORPORATION Cl LOCALAGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY AGENCY <br /> STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> y� g a /� C CARE OF ADDRESS INFORMATION <br /> r '��-C lAL-A L LLR. <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP <br /> CORPORATION ❑ LOCAL- STATE-AGENCY INDIVIDUAL 0 COUNTY AGENCY 0 FEDERAL-AGENCY <br /> JEHI <br /> E 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. 1�1-- II. E6k If. <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 /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME <br /> PHONE#WITH AREA CODE <br /> ff)on S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION COD CENSUS TRA It t 3UPERVI 0 Ll�R-DISTRICT CODE BUSINESSci PLAN❑FILED NO <br /> ❑ DATE FILFFf <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 1 I Y: <br /> 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 /> FORM A(3-2-88) <br /> DATA-PROCESSING COPY <br />