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STATE F CALIFORA WATER RESOURCES CONTRL BOARD <br /> A D <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> #TE FACILITY/SITE, INFORMATION and/or PERMI P I <br /> COMPLETE THIS FORM FOR EACH FACILITY <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF I MATZO r :j� ❑ 7 h'ANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 4911 6ARCA OFELOPOKI &TWAA,CA <br /> ADDRESS NEAREST CROSS STREET I ✓ to indca1' ❑ PARTNOMP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE q,WITH AREA CODE <br /> O CA ��ZIO C2o <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EEP`A 10 aa� O�Q �f C� <br /> ❑ ❑ TRUSRESETVLANDS ATION or ❑ CAD 'MZ 1p'`�' 0/O AT THIS SITE ��E <br /> 1 GAS STATION 3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) t_ PHONE a W TH ARE COOS <br /> A t �? -4503 a _ jh4 - 3 <br /> NIGHTS: NAME(LAST,FIRST) .. PHONE a WITH AREA CODE NIGHTS: NAME(LAS ,FIRST) PHONE a WITH AR CODE , <br /> NAEiAYA� REy t 5Z.- t3 S m - LEC-ace) - <br /> II. ROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> C, <br /> NAME CARE OF ADDRESS INFORMATION <br /> IJA 0 A <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> "' <br /> 0ftZ <br /> C1 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL 0 COUNTY-AGENCY <br /> ;NK <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CA 3 OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> AME CARE OF ADDRESS INFORMATION <br /> tJ W - <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 1 &RACA4 I ES ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE�O PHONE ,WITH AREA CODE <br /> t4SWP0A:t be'AGH 0k4)6S 225 <br /> IV. LEGAL NOTIFICATION AND BjLLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLI : L ❑ if. ❑ Ill. 75 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLLE ECT. <br /> APPLI NTS NAME(PRI TED&SIGNATURE) DATE <br /> I.a�Y 6ELL 7121/93 <br /> LOCAL A Y U ONLY <br /> [ COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> � � 2 �. } � cam-❑ <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME \Qin PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT q BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) 0 <br /> DATA PROCESSING COPY Alit' 1,S3 <br /> ,t►vv <br />