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STATE OF CALIFORNIA WATER RESOURCES CONTROL L _.RD sE <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM a" <br /> SITE 2FACILITY/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 CLO§P SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE [(J� <br /> 1.FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> -'e'c' —013 <br /> ADDRESS NEARESTCROSS STREET �✓1�Bn.„b.„ia.o�w ❑ PNfrow ❑ STATEJ,AM <br /> Z1,60mTDN ❑ IOGEJSBILY ❑ RIIERYAGINY <br /> T'�a2 S o'4: 1, �LL PA UCS Ci+ Inc= 0 <br /> NDNVA 11x cx4 g <br /> GN ITE P <br /> NAME STATE ZIP CODE SITE N.WITH AREA CODE <br /> S �p C K f o vL CA 7SSG 7 1G'i - 95 7-�• 2 6 <br /> TYPEOFBUSINESS. 2DISMIBI1TOfl 4PRDCESSOR ✓Bo%NINDIAN EPA 100 Not TANKY <br /> • I GASSTATION ❑3 FARM ❑ <br /> ❑ ❑5 OTHER TRUST IANOS ION I% ❑ AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(VST,FIRST) PHONE N WITH AREA CODE DA1'S: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> W lUnvyl� -�v� - Vil�asvPt 5is - tvc- �yz <br /> NIGHTS: NAME(LAST.FI RST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> (cxxay. ("i I-1 If wt DO-`7%1-3«7 F-Axo�� r4I4,t 64; v- - Y - 3C'/ <br /> It. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ACS f <br /> MAILING a STREET ADDRESS ✓Box la micale ❑ PARTNERSHIP O STATE-AGENCY <br /> fr - g'—CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0.C. C""V— ( C' .l)G r D INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONEN,WITHAREACOOE <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �= X O Lfl , J5di <br /> MAILING a STREET ADDRESS ��✓sy fo.w.le ❑ PARTNERSHIP D STATE-AGENCY <br /> n H�CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> S•� L/ 4✓C1 G�)�'�-L•� \ C �0 i� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME -STATE ZIP CODE <br /> /� PHONE N.WITH AREA CODE <br /> , t [ <br /> "G)0yy �OiG� <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(T)BOR INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, T BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT, <br /> APPU NT'SP ED N GATE <br /> .J. -U.�� ANALYST <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY# FACILITY ID# #of TANKS at SITE <br /> Q� I Z I I F7= <br /> CU RENT LOCAL AGENCY FACILITY ID N <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> EG A L CDq <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E%PIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT DISTRICT CODE BUSINESS PIAN FILED IDATE FILE 'T <br /> G 3 Z YES NO Y L� A I <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N B <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIOWS),UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> FORM A(z-2-SS) 1 DATA PROC -ING COPY 2 LOCAL AGENCY COPY 3 —ILE COPY <br />