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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA`: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� Z <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE °'��.•�-`" �� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 0211,CHANGE OF INFORMATION 7 PERM LY CLOSED SITE Ai <br /> ONE ITEM ❑ 21NTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> r <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS (y NEAREST CROSS STREET ✓Go NiW.* 0 PMTNERGSIP 0 STATE AGENCY <br /> J[ h A- �� ElCORPOYAnoN Cl LOCAL 11FEORUL AGENCY <br /> V v R ❑ INOMOIIAL ❑ COUNrv-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 9 5'_3-716 <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PROCESSOR I ✓Box d INDIAN EPA 10 N <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTY ATNDS ION or ❑ #of HIS SITANK'TE <br /> AT THIS SITE (/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(AST.FIRST) PHONE B WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(AST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE At WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 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: 1. ❑ II. ❑ 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 M JURISDICTION K AGENCY R FACILITY ID K #of TANKS at SITE <br /> 39 = = I I I / 53I ll <br /> d <br /> CURRENT LOCAL AGENCY FACILITY #� „/ APPROVED BY NAME PHONE WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION COD CENSUS2RAC3M SUPERVISOR-DISTRICT CO E BUSINESS PIAN FILED DATE FILED yyLL <br /> CHECK# PERMIT AMOUNT O SURCHARGE AMOUNT FEE CODE YES ❑RECEIPTIt <br /> NO ❑ /Y: v /\'r <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 ONLY. `p <br /> FORM A(3-2-88) V <br /> i ' <br /> \� \ � �`1 � `-, DATA PROCESSING COPY � - ✓ Fes/ <br />