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STATE OF CALIFORNIA WATER RESOURCES SCONTROL BOARD <br /> W <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> GCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE z <br /> IO <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACIL TY/SITE NAME CARE OF ADDRESS INFORMATION <br /> rq itiS Se rr,&- <br /> NEARESTADDRESS CROSS STREET ✓Rm losCi 0 PARTNERSHIP 0 STATEAGENp <br /> Ee 1 (/�. F F N 0 PIRATIC# 0 WUNlYLOMAAGEN 0 EEOER"=-AGENC <br /> BmB1u.L ❑ cau#TYACBIcr <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CO DE <br /> �J\' CA 5a os ao9 - a <br /> TYPE OF BUSINESS p DISTRIBUTOR4 CESSOfl ✓Box tl INDIAN EPA ID N #of TANK'# <br /> ❑ ❑ RESERVATION or 1:1 / V V , AT THIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST,LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,RBST) PHONE#WITH AREA CODE <br /> t, (ao9 <br /> 0_9V <br /> NIGHTS: NAME(LAST,FIRST PHONE#WI AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S (,ao4) 3-&7 74 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S a i e <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Scc rrL2 as S�`�� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 11 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.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. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> I <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> a6n / Z�= don <br /> CURRENT LOCAL AGENCYFACILI�0 APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO LCODECENSUS TRA # SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �` 3 1 � YES � NOCHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1(OR MORE TANKPERMIT FORM `B'APPLICATION(S(, UNLESSTHIS ISACHANGEOFSITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> .... DATA PROCESSING COPY -.r <br />