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STATE OF CALIFORNIA WATER RESOURCES CONTROL0ARD <br /> 1 f <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE FV <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITTENAME CARE OF ADDRESS INFORMATION <br /> Ry MIAll jWffiel <br /> ADDRESS NEAREST CROSS STREET ✓AwbidbYe 0 PARTNBffiIIP 0 STATE AGEWY <br /> 0 OMPATON Cl IZAL-AGENLY 0 FEUEEPAL-AGDO� <br /> +05 5. G Q ❑ INONDuu 0 COumr-AGBICV <br /> CITY NAME STATE ZI CODE SITE ONE N,WITH AREA CODE <br /> 5 CA ���ZD 83 --3w-1 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID N F of TANK'F <br /> RESER�1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST YLANDS ATION ur ❑ AT THIS SITE 4 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE P WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME 1^''�` CARE OF ADDRESS INFORMATION <br /> \[kcAsit D �.a'eCrL-F 130uR-. <br /> MAILING or STREET ADDRE ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 1 ft6 �� O CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> G— 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STAT ZIP DE PHONE ,WITH AREA CODE <br /> R 63,2--D 0 p)2)8_?7021 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAIUNG or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 ;TATE AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> ,CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL 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 N JURISDICTION M AGENCY R FACILITY IDM M of TANKS m(SITE " <br /> 39 [� <br /> 10 10 8 9 00 10 4 <br /> ffitj <br /> Y FACILITY IDN MPERMiT <br /> PHONE N WITH AREA CODE <br /> 14 <br /> PERMIT APPROVAL DATEATION DATEENSUS TRACTIf BUPERVISOi DISAN FILED DATE FILED <br /> 2 ((�/, 4?_ NO <br /> ERMIT AMOUNT SURCHARGE AMRECEIPT# 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 /> F RM A(3-2-BB) <br /> i <br />