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Asa y�3s�a <br /> STATE. A WATER RESOURCES CONTROL BOARD <br /> CPQ ••'`'y <br /> FORM `A' ERGROUND STORAGE TANK PROGRAM Yo <br /> SITE MA`VlIClr/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 44, <br /> FNVIRONMENTAL HEALTitOMPLETE THIS FORM FOR EACH FACILITY/SITE `qQ Fo " <br /> MARK ON&ER M ILIA SfiW ❑ 3 RENEWAL PERMITATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ©P_ <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 60th 7-A1- SA-slE <br /> ADDRESS <br /> NEAREST CROSS STREET ✓Boz to indcate J&PARTNERSHIP ❑ STATE-AGENCY <br /> 13 CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY Y <br /> SLOU0 QJL 61,v8 El INDIVIDUAL 0TY <br /> CITY NAME STATE ZIP CODE SITE PHONE At,WITH AREA CODE <br /> S-roC_/c fl CA cmD o S/ do 9-- 7y8- 05-7 <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR I ✓Box if INDIAN EPA ip# <br /> [:] ❑ TRUST LANDS or El AT THIS SITE <br /> 1 GAS STATION 3 FARM 5 OTHER <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 /> G,e/FfEN _Y� o? �- 9 y -os75/ E IS o t� G>��91 l� � , <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> C�k/f/=Enl <br /> 277EVIS 1)19 y",- // F44"Com/ 6 /111 alp y- C? <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 f4EI-L oll Sit-VA <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 11 g CORPORATION 13LOCAL-AGENCY ElFEDERAL-AGENCY , <br /> P (� 7�� 3 .❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Go,lGo2l� Gig SYS-,6 7& <br /> III. TANK OWNER INFORMATION &ADDRESS— ('MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 51 LL LCOQ f�l� Y SAW6 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> XCORPORATION ❑ LOCAL-AGENCY 13FEDERAL-AGENCY <br /> © o yDa 3 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME S.ATE ZIP CODE PHONE#,WITH AREA CODE <br /> cony 6A �'ySa yrs-� b iyiy <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. ❑ II. ill.❑ <br /> I <br /> THIS FORM HAS BEE OMPLETED UNDE13 PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLLIICAN ME(PRINTED&SIGN URE) DATEr <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® -An <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 5N E1_L_ 2�5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED22 n <br /> ZJ. <br /> 321 YES NO V 1 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT TEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATfbN*ONLY. <br /> FORMA(3-2-88)�� <br /> *� DATA PROCESSING COPY <br />