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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMW: d" <br /> UNDERGROUND STORAGE TANK PROGRAM ; � o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> — z <br /> L 10 <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 I•� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 53 N <br /> I. FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Ralf E ; mer <br /> ADDRESS <br /> CApm "T— <br /> FL NEgPE$TC OSSSTREET ✓Bpeb Mcffia 11 PARTNERSHIP1:1 STATE.pS[ryLy <br /> ZOS1 E. Cka 8 ��l WPPOPATION 11LMLAGEKY ElFILBULAGE10 <br /> I IN WGUAL ElODUWAGB49 <br /> CITY NAME STATE ZIP CODE SITE PHONE R,WITH AREA CODE <br /> CA 2 ol- -s o <br /> TYPE OF BUSINESS: ❑3 DISTRIBUTOR ❑4 PROCESSOR -/Box it INDIAN EPA ID N <br /> ❑1 GAS STATION ❑ 3 FARM 5 OTHER RESERVATION <br /> NDS or ❑ 4 of TA K's <br /> TRUSTSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAM�LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 204 333 2069 <br /> NIGHTS: NAM (LAST,FIRS P NE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> °` 333-266$' <br /> II. PROPERTY O NER INFORMATION StADDRESS - (MUST BE COMPLETED) <br /> NAME CAR OF ADDRE INFO MATION <br /> MAILING orBEET ADDRESS ✓So to indicate 1:1 PARTNERSHIP 11STATE-AGENCY <br /> 2 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Loci 20 -333-2068 <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> flf<F As <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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: L ❑ 11 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> m 10 10 11 In (0 In <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 YES ❑ NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> 1 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 ONL . <br /> 1 FORM q(3-2-SS) — <br /> DATA PROCESSING COPY <br />