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s <br /> STATE OF CALIFORNIA wATER RESOURCES C <br /> a <br /> FORM `A': UNDERGROUND STORAGE TAN <br /> W <br /> ° <br /> SITEl FACILITY/SITE, INFORMATION and/or PETWA LICATION <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION - 7 PERMA 1_ SITE N <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE —4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME <br /> C 72,G*CL- W' w <br /> ADDRESS ;{ N AREST CRO58 STREET ✓Boa loi ate!i ❑ PARTNERSHIPEN ❑ STAEE-A AGEN <br /> ��6pAPpRATi�N Cl COUNTY-ADEN Q FEDERAL AGEHLY <br /> g{P@NIWAL .ik Q COUNTY-AGENCY <br /> CODEs STATE ZIP O �./� SIT PH?NE H AREA <br /> CITY NAME r� <br /> CA <br /> TYPE OF BUSINESS: 2 OI$TRISUTOR4 PROCESSOR ✓Box rf INDIAN EPA lD q 1!of TANK'f <br /> 0 RESERVATION or ❑ AT THIS SITE d <br /> ell 15 STATION El 3 FARM L]5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME{LAST,FIRST) - PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PH7AA E#WITH AREA CODE <br /> )36`i- _7 SS <br /> NIGHTS: NAME(LAST.FIRST) I PHO £R WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> -CIA4 I/A SIA <br /> II. PROPERTY OWNER INFORMATION &ADDRESS-- (MUST BE COMPLETED) <br /> Na�F CARE OF ADDRESS INFORMATION <br /> g <br /> MAILING or ST ET ADDRESS /+ ✓Box to indicate- ❑ PARTNERSHIP : ❑ STATE-AGENCY <br /> W <br /> El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 30 v1N f .�.(�A�[,(/ ❑ INDIVIDUAL Q COUNTY-AGENCY'IF <br /> CITY NAM - STATE - ZIP COf� <br /> T <br /> HONE M,WITH AREA CODE zyz - I t3z <br /> Ill. TANK OWNER INFORMATION &ADDRESS-(MUST BE COMPLETED) i <br /> NAME � CARE OF ADDRESS INFORMATION <br /> ZA � <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE q,WITH AREA CODE <br /> ji <br /> n <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.' Rr IL 0 Ill. <br /> I <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 3 SIGNATURE) - DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# AGENCY k FACILITY ID 0 #of TANKS at SITE , <br /> J L lo_j6F_tTC, ;j 15�1 1 ,5loToT)l <br /> CURRENT LOCAL AGENCY FACILITY ID! APPROVED BY NA E PHONE M WITH AREA CODE r <br /> 3 <br /> PERMIT NUMBER PERMIT.APPROVAL DATE O&MIT E%PIRAT NDA <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR- ISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 15 „' \ YES E] NO e--,, I _. //q/ <br /> CHECK li PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT f BY: f <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY it <br />