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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM `moo <br /> SITE FACILITY/SITE INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c Fqp"R <br /> [MARK ONLY ) NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q <br /> r0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITYf SITE NAME CARE OF ADDRESS INFORMATION <br /> ociia I� �e 'c ry <br /> ADDRESS NEAREST CHCSS STREET ��✓.,�toindicale ARTNERSHIP ❑ STATE AGENEN <br /> �/�� /� /� y/. VORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> q,3 ,/1 j''r'I I ,c3 r'' �J %� (•'�'�( ! J~J ! + ❑ INDIVIDUAL ❑ COUNT('-AGENCY <br /> CITY NAME L/ f l STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> cAaD2- ao9 5� 44 <br /> TYPE OF EsUSINESS: p DISTRIBUTOR 4 PRDCE55011Fl,/Box if INDIAN EPA ID # #of TANK's <br /> f GAS STATION 3 FARMOTI ER USTESEFIVATION LANDS or <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 14a ro I d- ulo m b l i Prii ao4} yo, -tik7 <br /> NIGHTS Ll ,FIRST PHONF#WITH AREA CODE NIGHTS, NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> 2 6 0731- <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ✓ to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS <br /> 1 7 ❑ El <br /> ❑ LOCAL-AGENCY [I FEDERAL-AGENCY <br /> 1� INDIVIDUAL COUNTY-AGENCY W] <br /> CIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S a,m e a s ' <br /> ✓ <br /> MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP [71STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ II. 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* JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I I - I / I / I :Fm k2L0 17ou <br /> CURRENT LOCAL AGENCY FACILITY ID# APP VE BY NAME 104 <br /> PHONE#WITH AREA CODE <br /> 13 OCKM <br /> GU L� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# 7IS ERVISOR-DIS?TRRICT CODE BUSINESS PLAN FILED DATE FILED r <br /> [! vC , k 0 YES ❑ NO ❑ l �0 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B <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 ONLY. <br /> FORMA(3-2-86) <br /> ,5 �5 0 DATA PROCESSING COPY <br />