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10 <br /> STATE OF CALIFORNI WATER RESOURCES CONTROL ARD <br /> O <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM fta <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> U�2 I _­_ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 'OFOR"'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE q <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 10 <br /> FACILI /SSInI�TE NAME Q CARE OF ADDRESS INFORMATION <br /> K co I�0 1� . woltV <br /> ADDRESS NEAREST CROSS STREET ✓ <br /> Box tointlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ) ❑ CORPORATION 1:1 LOCAL-AGENCY ElFEDERAL-AGENCY(� <br /> Off., C Of � [jj�IVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE V 1 <br /> 7kAcY CA r2bq <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ ❑ TRUSTRESERY ANDS ATION or ❑ Q I D u #of HIS SITE <br /> 4 <br /> S STATION 3 FARM 5 OTHER N � AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(AST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Iw <br /> NIGHTS: NAME(AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME Q CARE OF ADDRESS INFORMATION a <br /> MAILING or ST EE ADDRESS ✓Box to indicate ❑ PARTNERSHIP 11STATE-AGENCY <br /> ❑ COFXORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> rr LU-111DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> �Xw2 L fMA O ft q L�I <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <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#,WITH AREA CODE <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. ❑ 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'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3 � I Er I 1 10G18, ul Lo 6 k Fj] <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �V&LEG—3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE p. P RMIT PIRATION DA <br /> �1 <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Cj �3ou Y- F � <br /> a— YES ❑ NO ❑ <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 INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY ' <br />