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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD "E <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM V " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS / <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY El ( NEW PERMIT ❑ 3 RENEWAL PERMIT EJ-5 CHANGE OFINFORMATION El 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION C <br /> 7��n,V 0/0 sFfoP F W vW FGOKG� <br /> ADDRESS NEAREST CROSS STREET ✓Ew IP MI ❑ PARTNERSHIP Cl STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY [I FEDERAL AGENCY <br /> CITU NAME <br /> AGENCY <br /> STATE ZIP CODE Cl INONIDUAL ITE PHONE pmWITR AREA CODE <br /> ��UG 'Z'pnt CA �Zb Zo�1) Z��Ij� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P q ✓Box if INDIAN EPA ID p <br /> ❑ 1 GAS STATION ❑ 3 FARM 5OTHER TRLISTyI ION <br /> OSor If of TANK's <br /> ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> /�oA2Fs AREACODE 4 (LASTFIRST) PHONE <br /> p WITH ARcr DE��v� j4Z'I3 Gic- 4S Vy)^/i (�)cl3L6t <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inootite ❑ PARTNERSHIP ElSTATE-AGENCYP o. 552 11 11 <br /> El LOCAL AGENCY ❑ FEDERAL AGENCY <br /> 11INDIVIDUAL 13COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> �o�o C,�- �j5Z0 �Zbci)431-64// <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> G£ . /-ua <br /> MAILING STREET ADDRESS dI�1 ✓Bax to intlioate 1:1 PARTNERSHIP ClSTATE-AGENCY <br /> ` 4 �� � ^/J ClCORPORATION 13LOCAL-AGENCY11 FEDERAL-AGENCY <br /> L ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE / PHONE 4,WITH AREA CODE <br /> s7D [Oel/ LX- g577- (2o-T) R3/-6Q </ <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. ❑ if. ❑ 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 8 SIGNATURE) PATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION It AGENCYIN FACILITY ID M N of TANKS of SITE <br /> 3 �n O d 1 11 17 2 0 0 o3 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> SNF ?;Z- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE C�EEN2SSUS TRACT N SUPER.VIISORR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL 0 <br /> 0 � l��� �J YES NO � <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N By; <br /> T <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. �\ <br /> FORM A(3-2-88) "�ffffffj <br />