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or., <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m I <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE IJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FAC /BITENA Etat& `�I CARE QA�RESS INFORMATION <br /> AD RE� r / /1 NF*�-�ITIen^i,TREETKK ✓Bw wrdrsk ❑ PARMEPSHIP ❑ STATE AGENCY <br /> C� Q LTN G��U� , (/V,, r• DD EAN <br /> O INca AIDUAll CD EE�ArGEN ❑ FVEPu ACExcr <br /> CIN NAME(_0I BTATCA Z CODE SITE PHONE p,W TH AREA CODE <br /> E^IM�. 1. !V 24 3Dy8 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p <br /> ❑ 1 GAS STATION ❑ 3 FARM �5 OTHER TRUSTYLANDS dr ❑ AT THIS SITE <br /> u UKP <br /> k of TANK's <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> ( 6 era4ors" 0q 369-03S <br /> ,PIGATS NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> eralors# oar �g7_S <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMA ON <br /> S I <br /> MAILING OIS15EET A DR 85 1 ✓Be.to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> f / ❑ CORPORATION JrLOCAL-AGENCY 0 FEDERAL-AGENCY <br /> I /" ❑ INDIVIDUAL LJ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> 36�s— <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> I NAME CARE OF DRESS INMATIONFOR <br /> " F)4, <br /> S tGN <br /> MAILING o,STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION OgLLOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 1 LANe- 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE <br /> d (flf 333-69y0 <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: I. El if. El 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 R JURISDICTION N AGENCY R FACILITY ID N If of TANKS at SITE <br /> 10 0 1DOD <br /> CURRENT LOCAL AGENCY FACILITY ID X APPROVED BY NAME PHONE X WITH AREA CODE <br /> 03 <br /> PERMIT UMBER PERMIT APPROVAL D TE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERY 20 -DIIS T CODE BUSINESS PLAN FILED DATE FILPD <br /> O L• / YES NO I I C' <br /> CHECK N PERMR AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: <br /> ` , ITHIS 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 <br /> FORM A(3-2-88) <br /> I 1 DATA PROCESSING COPY `� <br />