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OF <br /> STATE OF CALIFORA WATER RESOURCES CONTROL BOARD <br /> FORM `A°. <br /> UNDERGROUND STORAGE TANK PROGRAM no <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE F <br /> Cq�IFO <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE IIs <br /> cy <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) �: <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Precissi Flying Service John Precissi <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 11919 Lower Sacramento Road Armstrong Road ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Lodi . 95242 CA 95242 209 369-4408 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID.# <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER RESERVATION or #of TANK's <br /> TRUST LANDS CAC 000543856 <br /> El 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 If WITH AREA CODE <br /> John Precissi 209 931-2599 Peter Precissi 209 369-45 8 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#,WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> John Precissi 2 931-2599, Peter Precissi 209 369-458 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Precissi Flying Service John Precissi <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 11919 Lower Sacramento Road ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Lodi, CA 95242 1 ( 209 ) 369-4408 <br /> I11. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Precissi Flying Service John Precissi <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑'PARTNERSHIP ❑ STATE-AGENCY <br /> 11919 Lower Sacramento Road ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Lodi, CA 95242 1 ( 209 ) 369-4408 <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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# - JURISDICTION# AGENCY# ACILITY ID# #of TANKS at SITE <br /> I <br /> 3 <br /> E:()_L <br /> i <br /> URRENT LO AGENCY FACILITY D# AP VED BY NAME PHONE#WITH AREA CODE <br /> I <br /> PERMIT NUMB R PERMIT APPROVAL D PERMIT EXPIRATION DATE <br /> LOC <br /> ATIO CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D 3. <br /> YES ❑ NO ❑ ( �� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY*� <br /> sism <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 OR MORE TANK PERMIT FORM `B'APPLICATION(S), UN 4S THIS IS A CHANGE OF SITE INFORMATION ONLY. .. \0. <br /> FORM A(3-2-88) /rte <br /> ATA PROCESSING COPY <br />