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STATE OF CALIFORNO WATER RESOURCES CONTROL BOARD /s` ';f <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION val�o 0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM 02 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) U,, Cm <br /> FACILITY751TE NAME CARE OF ADDRESS INFORMA ION <br /> ecc- icJk,o re Sin err 5i fn <br /> ADDRESS NEARESTCROSS STREET ✓Boa loitdPate ❑ PARTNERSHIP 0 STATEAGENCY <br /> e Y 0 CORPORATION 0 LOCAL AGENCY <br /> 0 FEDERAL AGENCY <br /> CITU NAME STATE ZIP CODE Z SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS ��-ems CA `(S ..�JCp Cl A , <br /> ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Bax if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARMTRUSfHEfl RESERAT THIS SIT <br /> VATION or ❑ N of TANK's <br /> ��� <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS AME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> (�'eiI 5. res. _01"i -Sl-70 <br /> NIGHTS. NAME(LAST,FIRST PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) ^_ PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sar►L�, c....o � <br /> MAILING a,STREET ADDRESS -/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME ^ A CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. it. ❑ 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 /> COUNTYIN JURISDICTION R AGENCYIN FACILITY ID N N of TANKS at SITE <br /> = = 1010 11 -1 Iq 131 1 aaov <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> 4h)Te <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CO E CENSUS SUPERVISOR-DISTRICT CODE BUSINESS, N FILED AT C � SFNG FILE <br /> ao <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ON��I <br /> C\ FORM A(3-2-88) <br /> V � DATA PROCESSING COPY <br />