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r <br /> STATE OF CALIFORNR WATER RE <br /> SOURCES CONTROL BOARD �y�'•EV ntr�'�F•� <br /> FORM `A': t <br /> UNDERGROUND STORAGE TANK PROGRAM =`� B 0 <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE FOR"P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑J5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 7 <br /> J <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) O <br /> FACILITY/SITE NAMEr CARE OF ADDRESS INFORMATION <br /> Pa C r -i r /3 P fV <br /> ADDRESS NEAREST CROSS STREET A to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 0) <br /> 9 O �� ' \f nC0 f n J CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY M <br /> /\( t� I k, (� ❑ INDIVIDUAL ❑ COUNTY-AGENCY W <br /> CITY NAME ��/� ��� '/� STATE Z�C O 7 1(;�oq)41 <br /> ySITE PHONE#, YHARLI��CODE!\ <br /> TYPE OF BUSINESS: C❑J 2 DISTRIBUTOR ❑4 P OCESSOR ✓Box if INDIAN EPA ID # ! t_ <br /> RESERVATION or ✓�[��,� #of TANK'S <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ t"' ""�r AT THIS SITE ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME IAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> D. u'% r1 QV1fS ocf) Lf-74-4300 FE me V, ev�C Coofro `ftp S23 7777 <br /> NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NA (LAST,F T) PHONE#WITH AREA CODE <br /> F011f P11C f 0 7777 <br /> II. PROPERTY OWNER 64FORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION <br /> teac ; G i3e l i <br /> MAILING or STREET ADDRESS _ ✓fox to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> El a wl Ism a L SO CORPORATION LOCAL-AGENCY FEDERAL-AGENCY <br /> Co ,Y� ( Y� v rU ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> F r e s rV O q '�S k' 3 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NA E `� _ CARE OF ADDRESS INFORMATION <br /> GCr �iG f�Pl1 <f PSN duPl G/vlrt <br /> MAILING or STLR,EET ADDRESS <br /> n �f {� (� ✓ x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> MIT/ ! T S 1' �"[ '1 ,✓r S S /j u e. Rt4A �3� DIIVIDUALION ❑ COUNTY AGENCY D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> wo `>371oa <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. ❑ 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 /> CURRENT LOCAL AQENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> r, C l 10 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE}FILED-1 1 r/ <br /> .^ YES NO [:] / '?3 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Y: <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 /> FORMA(3-2-88) <br /> • LOCAL AGENCY COPY • <br />