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STATE OF CALIFORNIP WATER RESOURCES CONTROSOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM `. . .. o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION «,; 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION [Zl PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE SD <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> O <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Leon I . Lal, LsL_0.,aQ I_- ctTT , <br /> ADDRESS NEAREST CROSS STREET ✓Box to WI ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 1 J�—T �C' m 1 1 A ❑ CORPORATION 1:1 LOCAL-AGENCY ❑ FEDERAL <br /> Ill l E LNIDUAL ❑ CO'JNIYAGENCY <br /> CITY NAME 1� STATE ZIP CODE SITE PHONE IT,WITH AREA CODE <br /> 1 ' 1A_nlX _Cy CA as �J31-P oloc'S `6 a3-10_) <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR -/Box if INDIAN EPA ID # <br /> ❑ f GAS STATION ❑ Al [TANK' <br /> 3 FARM OTHER TRUST LANDS ESERVATION Or ❑ ATT IS SITE 01 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> �e7neL j L , n aOq�d o�9 <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE ft WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sa � <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME C CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 11PARTNERSHIP ❑ STATE-AGENCY <br /> 11CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.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. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION M AGENCY# FACILITY ID M A of TANKS at SITE <br /> � 91 001 al 3 B O Uv I <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE <br /> L£ COn (:) 1U <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED ATEFILED <br /> 'l,3O YESE] NO /%% lCW <br /> CHECK 0 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 0 BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION 0: <br /> FORM A(3-2-88) • <br /> DATA PROCESSING COPY <br />