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- ..,+.r'•2 r.r^err ... r'r' .,a„rte. yni:+,ra..a:,`• ,-u' r . _.- .r' -'�✓..^•�� rrar .. ..s�u•�,. _ ,. .. ..,Y,r". .��-..t!r:.r.r'�iF x',r,Cnr:i <br /> STATE OF CALIFORNIi WATER RESOURCES CONTROOARD <br /> i f <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ab <br /> �� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARYSITECLOSURE 997 <br /> so <br /> I. FACILITY/SITE INFORMATION &ADDRESS'— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> _gr . , G r e �oY»meecial Fue�in N <br /> ADDRESS �}� .Q - �; N EETS ,.✓, aptom irate ❑ PAATNMIP ❑ STATE4119LY Ln <br /> o I Q C( ! C_ A L) �+ L� U!A+'ORpTION ❑ CIMM-ADEN ❑ FEDEfY1.AGEfA,I' <br /> ❑ wDNIDUAL ❑ r,DIjIVTYdGENC! <br /> CITY NAME STATEZlft&E S E PHONE#,WITH AREA CODE <br /> -c, <br /> S�CC,K4 CA a 09 IkP4,-,5?a1 <br /> TYPE F BUSINESS: F72 DISTRIBUTOR F74 PROCESSOR ✓Box it INDIAN EPA D # <br /> RESERVATION or #of TANK'a <br /> GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ 'v ,U AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) .PHONE#WITH AREA CODE <br /> rD 4c3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE it WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> sem_ ao4 7-aa <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r 1� <br /> MAILING W STREET ADDRESS ✓B99to indicate ❑ PARTNERSHIP 13 STATE-AGENCY <br /> UltORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> r.l y ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME Q J STATE� ZIP O 01 �IT D <br /> III. TANK OWNER INIFrORMATIT{IJONN_J&t ADDRESS — (MUST BE COMPLETED) <br /> �`lJ <br /> NAME n _ CARE OF ADDRESS INFORMATION <br /> MAIG Or STREET RISS J ✓ x o indicate 13 PARTNERSHIP ClSTATE-AGENCY <br /> D . f 2, O ❑ INDIVIDUALPORAT <br /> ❑ COCl UANTY AGENCY ❑ FEDERAL-AGFJdCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> E G"910—o ���sgar <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: 1. ❑ IL ❑ HI. <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 10 1f N of TANKS a1 SITE <br /> [711' 003 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PAC <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DI CODE BUSINESS PLAN FILED DATE FILED <br /> 3 I YES NO 5 <br /> CHECK N PERMIT AMOUNT SURC14A AMOUNT FES CODE RECEIPT N 8 <br /> I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A 13.2-88) <br /> C � <br /> DATA PROCESSING COPY .�.J <br /> II <br />