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-7 D9y3 <br /> .n �- a �_ <br /> STATE WATER RESOURCES CONTROL BOARD °` T" <br /> FORM `A': � • m <br /> MAY 2 1 1,PMNDERGROUND STORAGE TANK PROGRAM Y �o <br /> SITEI IINFORMATION and/or PERMIT APPLICATION <br /> ENVlRONGi`I r �'COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> C'q CIFO RNP <br /> ES <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> Ospe <br /> NE 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 y�R <br /> QA-cY 1+61-c M161 MAk7r Aol 6 <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /� /� Q ElCORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCYRA(- 34,VP . CLO GF �INDIVIDUAL ElCOUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> kACY CAn_95-,3-)&953-)0 O'- 3S- ),(90e? <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ 1ATTHISSITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> COX CARL- ad?- M- WkC GARY ad 9- -d gal <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> coK-14 R �� " 83d 0'7 044WIF &A,0' 091- 9'3(0.C)l)a <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 H-6tt olc (014�PAf"IY s6*,16 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> I�CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> P. o. Dai ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> co r4 wzD <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME GCARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> P U• 13 v yt)o)3 ❑ INDIVIDUACORPORATL El <br /> Cl LOCAL-AGENCY El COUNTY AG NCY E) FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE r PHONE#,WITH AREA CODE <br /> 69 f4 Wrelo 64 6 <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. 0- <br /> . ❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT' IQ S DATE <br /> X 07) 4- 4 . &)l r7—f <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> m <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME 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# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UN ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) • <br /> DATA PROCESSING COPY , <br />