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STATE OF CALIFORNIA WATER RESOURCES CONTRAOARD <br /> UNDERGROUND STORAGE TANK PROGRAM =" f wo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ``-rFoNr`" <br /> MARK ONLY ❑ 1 NEWMRMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> cn <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> VAI—/,E 1' Gly/dLvj F <br /> ADDRESS w ' NEAREST CROSS STREET ✓8ocwnpkale, Cl PARTNERSHIP ❑ STATE AGENCY <br /> !p O ✓Jl4 /O� �j'-�' ❑ COHDPA'fISN ❑ LOCAL AGENCY ❑ FEDERALAGENLV <br /> GIYIWAL ❑ 000N1Y-AGEND <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH REA CODE <br /> !/ CA g5Zv 2�i� 416a-4fg0Z <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 SSOR ✓ROA iI INDIAN EPA ID p <br /> ❑ I GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ AT THIS SITE U <br /> ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH APEA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> �k�i`✓ 066 Zoa] �6 �/� <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NA E CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box IO HHHc w ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> E❑�ORP9RATION ❑ COUNTY AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTYY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.WITH AREA ODE <br /> 577 v� G/d — Zo-7 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> _Aj <br /> MAILING or STREET;A7FESS ✓BouE0,NN,cale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> W , ��GwK� • �v' ❑�PNOIVIDUAL RATION 13 COUNTY-AGENCY AGENCY D LOCAL AGENCY ClFEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE 0.WITH ARE_ ODEI�O <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ If. 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 M JURISDICTION Y AGENCYAF FACILITY ID X N of TANKS at SITE <br /> 6) 1 c) Z 1 1 1 1 1 1 (0 <br /> CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT K SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE qLE / <br /> 0C 3 • S--o SU/Z,5 YES NO E] O <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M , <br /> - i <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. IN <br /> FORMA(3-2-88) <br /> � G) I 0 DATA PROCESSING COPY <br />