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m <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> W <br /> UNDERGROUND STORAGE TANK PROGRAM = " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> e COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT >VCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 44 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/ NAME CARE OF ADDRESS INFORMATION <br /> S oc ra ter � ro <br /> ADDRESS / NEAREST CROSS STREET Mind, 0 PARTNENRIIP 0 FATE-A(#NLY <br /> deme er L glllEl kNrt . L co3raunox ❑ locl_ACExL. ❑ Ro LacExc <br /> of P,ne S I . ❑ INomouu ❑ couxnacexcr <br /> CITY NAME STATE ZIPCODE 2 1 510 f ONE k,W6 AREA ID3 <br /> S �� CA ,S �T((�O <br /> TYPE OF BUSINESS: p DISTRIBUTOR 4 P 0CEWR ✓Box if INDIAN EPA ID p N of TANK's <br /> ❑ I GAS STATION 3 FARM OTHER RESERVATION or N <br /> ❑ TRUSTLANDS ❑ /V D n P.► AT THIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 1 <br /> Gil ber f gai, i el 00(05- 13 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> S cL rl'e <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> cKJ U rat <br /> e ter I <br /> MAILING or STREET ADDRESS �' ox to intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ORPORATION 0 LOCAL-AGENCY 0 FEDERA -AGENCY <br /> ld ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY N_A�jt STATE ZIP CODE PHONE p,WITH AREA DE <br /> Cg g5do I ao� S-Sa13 <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SQ <br /> MAILING or STREET ADDRESS ✓Box to intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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. ❑ 11. r54 III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a AGENCY a FACILITY ID R R of TANKS at S1TE <br /> m I d dl � s 0 00 / <br /> CURRENT LOCAL AGENCY FACILITY ID N APPR E BY AME PHONE a WITH AREA CODE <br /> S,fo <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERNI EXPIRATION DATE ' <br /> $ 11 88" <br /> LOCATION CODE CEN�STUS TRACT* SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED � <br /> 0 <br /> 1 Q(3 s PO r YES [:] NO i <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 DNS <br /> FORM A(3-2-88) J\ <br /> DATA PROCESSING COPY �� <br />