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77 <br /> STATk OF CALIFORNIA WATER RESOURCES CONTROLOARD �yf "'K�"T"� <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM <br /> r �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE " 'FORW <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 00"5 CHANGE OF INFORMATION ❑ 7PERMA OSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE z <br /> l - <br /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME i CARE OF ADDRESS INFORMATION <br /> 2320 C>0 Q--Q0 00 <br /> ADDRESS NEAREST CROSS STREET ✓�tlatoindicate ❑ PARTNERSHIP ❑ STATE-AGENCY (� <br /> 2-3 zo p4 o a:i C 1 ����DO Al>A M s L?CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> L t �'i vV ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE f� <br /> S b�k-To►.� CA 9 5Lo 4 0_0 C0143 Ili i <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID# <br /> RESERVATION or #of TANK's 3 <br /> 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUST LANDS ❑ 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 /> Kc131' o� �.pnE <br /> 040(p-1414 SNE�-i�_ C>r►. 60tR&-W (415)'0671414 <br /> NIGHTS: NAME(LAST, RST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S a-M 0 ps A6ov gr SAME ASS . E <br /> II. PROPERTY OWNER INFORMATION &ADDRESS,-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION Sul E <br /> 5 OIV GoNP�tii i3901r.1 �� ; A .RD. <br /> MAILING or STREET ADDRESS!!1� ✓@.4,X to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> i-1 yAcc Q C 1 1� �/\�. l20RPORATION ElLOCAL-AGENCY _ ❑ FEDERAL-AGENCY <br /> 1 <br /> 370 W 1 Irl . J v ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CX>4CoR-P cA. 9 4sZC> (,0s) 6-1 w-14 ij <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SRF,"- Oil- 1390 W 111c3w R6. SLj gs 90 o <br /> MAILING or STREET ADDRESS Y✓�ox to indicate ❑ PARTNERSHIP [ISTATE-AGENCY <br /> 13 �V l <br /> y,' 1 j� (� C CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> OW YP5RD JUITE LK 900 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Cofju>1ZD 9452-o CAIS) 6_76-1414 <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. El11.54 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 8SI RE) DATE <br /> 121ca� M�CAt,1EY, i�� la.►7 PA Foto si+Q L 1 2- Z9- <br /> s <br /> LOCAL AGENCY USE ONLY <br /> FPERER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> E[ I V910 I / I DEE Old 0 <br /> AGENCY F CILITY ID# A _1 <br /> PPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS YPLAN❑FILED NO ❑ D> FILED ^� <br /> B `(f <br /> AMOUNT SURCHARGE ALIOUNT FEE CODE RECEIPT# <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 INFORMATION ONLY <br /> FORM A(3-2-88) <br /> Al\ `� DATA PROCESSING COPY <br /> 5 <br />