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STATE OF CALIFORNIA WATER R <br /> FORM `A': ESOUIRCES CONTROL ARD PL Bo BSE <br /> w= F s <br /> UNDERGROUND STORAGE TANK PROGRAM �W <br /> SITE FACILITY/SITE, INFORMATION an /or PERMIT APPLICATION <br /> COMPLETE THIS FORM FORE EACH FACILITY/SITE - 4 <br /> Cy LRN`s <br /> MARK ONLY ❑ I NEW PERMIT <br /> ❑3 RENEWAL PERMIT CHANGE OFLINFORVATION ❑ <br /> ONE ITEM ❑2 INTERIM PERMIT 7 PERMANE�aaNTLY CLOSED SITE <br /> ❑4'AMENDED PERMIT 6 TEMPORARYLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME „v <br /> SPh^ CLQ CARE, /ADDRESS INFORMATION <br /> ! .. <br /> ADDRESS r ( 64 V, on���� I <br /> /y j NEAR STCROSTSTREET ✓ pWn ate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CITY NAME CJ f •7 {, / A __6 - ❑ RPO RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I l .F _ �[f INDIVIDUAL Cl COUNTY-AGENCY <br /> i /� I` STATE ZIPC DE <br /> Soo[ k.'T' 1 i s ) _i ' SITE PHONE#,WITH AREA CODE <br /> 1 TYPE OF BUSINESS: ❑ T A z�-/ „ { •-•� �'., yj' �� <br /> 2 DISTRIBUTOR /4 PROCESSOR ✓Box if INDIAN EPA I # <br /> I� ❑ I GAS STATION ❑3 FARM 5 OTHER RESERVATION or #of TANK It <br /> TRUST LANDS ❑ 0 iNip— AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) <br /> DAYS: NAME(LAST,FIRST) <br /> EMEF GENCY CONTACT PERSON(SECONDARY) <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> �e,z kwo J � �•J/�- 3` _/y� c _ PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST.), J+1 PHONErN WITTH AAREA CODE NIGHT,,:•-iN/A7ME(LASTIRST) <br /> 1, <br /> J /'� PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST E E COMPLETED) <br /> NAME/ <br /> C�y�7RKJE�ss <br /> / f [CA ADDRESS INFORMATIONMAILING or STREE�7^�,firox to indicatEl STATE-AGENCY <br /> PAR NERSHIP`� � 2 2-1 ORPORATION ❑ LOCAL-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME - DIVIDUAL ❑ COUNTY-AGENCY <br /> ZIP�,ppET// P ONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME / ~~ <br /> �,�,�J �� • ' CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓B x to intlicate ❑ PARTNERSHIP <br /> ❑ RPORATION ❑ LOCAL-AGENCY ❑ STATE-AGENCY <br /> ❑ INDIVIDUAL ❑ FEDERAL-AGENCY <br /> CITY NAME ❑ COUNTY-AGENCY <br /> STATE 'ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS - <br /> CHECK ONE(1j BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATI�ANDILLING: f. II III <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND T THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# - <br /> FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVEDBYNAME <br /> ✓ I S�6 PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> ERMI7 EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE <br /> 2--3. G3O �� USINESS PLAN FILED NO DA �L D <br /> (� YES ❑ if <br /> CHECK# PERMIT AMOUNT SURCHARGEFEE COD RECEIPT# B <br /> AMOUNT Y ( f f <br /> Y. <br /> TRIS FORM MUST BE ACCOMPANIED BY AT LEAST OR YORE TANK PERMIT FORM `B'AP ICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A{3-2-88} <br /> �. tF <br /> ��.. FILE COPY 7 <br />