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TATE OF CALIFORNR WATER RESOURCES CONT BOARD <br /> S <br /> FORM 4A': 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 ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 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 <br /> ahlrs 13race /-�a-�cllrcx l4` <br /> ADDRESS NEAREST CROSS STREETbPdvsk, ❑ PARTNERSHIP ClSTATE AGENCY <br /> / //��,, ❑ W✓BmR'OMTION ❑ LOCAE-AGEWY ❑ FEDERAL AGENCY <br /> 8666 iPl Es COYO rr�N ❑ INDNIDUAL ❑ COUNTY AGENCY <br /> CITY NAM STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> ( nJ CA `I5336 <O9-� 4 -23 2 <br /> TYPE OF BUSINESS ❑ ❑DISTRIBUTOR F-14 PROCESSOR ESERVAT DI or EPA ID N <br /> M o1 TANN'# <br /> ❑ i GAS STATION 3FARM ❑ 5OTHER TRUST LANDS AT THIS SITE <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 /> ��afclt c)r. t3tj,10.51 .20Q-<- —2312 <br /> NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ryN/15 0 <br /> .4C OC k <br /> MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 11 NDIVIDUALION ❑ COUNTY AGENCY 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> p'lp"pl-i C '75 X36- <br /> 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(II BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. 0111. ❑ <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 /> COUNTY11 JURISDICTION R AGENCY R FACILITY-fDiT� R of TANKS BI SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> MKT A115� <br /> PERMIT-HUMBER_..—___ __— ROYAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> -' 2 < 7 Z 6 YES ❑ NO ❑ /7 <br /> CHECK# PERMIT AMOUNT SURCHA GE AMOUNT FEE CODE RECEIPT# <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-88) 0 <br /> 0 <br />