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STATE OF CALIFORNIAWATER RESOURCES CONTR09OARD <br /> W <br /> FORM `A': 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 ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE FRI <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> /CB K CAA w*14 MrN a k.N v-rso 4 <br /> ADDRESS NEAREST CROSS STREET ✓Butiirtiule 0 PARTNERSHP 0 STATE AGENCT <br /> 601 E- hrri AVE. <br /> L Cl CARNRATION 0 LOCA AGENCY 0 FEDEPAL AGENCY <br /> /�1 0 INDP/IDUAL 0 COIINIYAGENCY <br /> CITY NAME STATE ZIP CODE I SITE PHONE N,WITH AREA CODE <br /> S-r-&-KrbM CA `t.SZo 2— Czaa) zl zs5/2 <br /> TYPE OF BUSINESS'. EPA ID N <br /> 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN <br /> GASSTATION ❑ 3FARM ❑ 5OTHER RESERVATION or ❑ - FOf <br /> TRUST LANDS AT THHISIS 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 /> M-rHle KMo-r5o (zDA) N65- z5g2- PET£ G1AA BANfo (z�T) Sz3- grvo <br /> NIGHTS. NAME(LAST.FIRST) PHONE N 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 /> V(Wr E r-A 2 w45W Pa-rc G14.�rt3.l��v <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> Z^ //��,,r7t A�t 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> oLo ST14Njd l Z/`3 .4ve. 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 14D1)ESTO � RS35'D (ua) Sz3- Firoo <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> v I N-r4 E cAA cv4.4fd <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> .1 /� /� d ❑ CORPORATION Cl LOCAL-AGENCY 0 FEDERALAGENCYZoZO 5-7—AMOO FOQ.D •AVE• 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 00E57-0 c/k 45 3S,0 ZOR) Sz3 _ g/oo <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 2r 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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION M AGENCY N FACILITY ID S B of TANKS at SITE <br /> EH] o 1 o t ( 8 3 3 <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE F WITH AREA CODE <br /> S/�IJ(T (DO <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED <br /> 01 73. D V 3 _3 YES NO fZrs�194o <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE{ACCr/OM, / <br /> ACCOMPANIED c, <br /> AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A MU <br />