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STATE OF CALIFORNI)v WATER RESOURCES CONTRUeBOARD y ' 0" <br /> FORM '#': UNDERGROUND STORAGE TANK PROGRAM V <br /> m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °'<,fon1 <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ke1 IN o 6ww1cd Mozeb <br /> ADDRESS NEAREST CROSS STREET ✓6pbn0irne ❑ PARfNERSIW ❑ STATE AGENCY <br /> ,,pp ElODWMTION 11 LOCNAGENC/ 0 FEDERAL AGDICf <br /> 1/57`7 (' p r`� Ya,4e( e__ ❑ rtoli ❑ COUNlyAGENC` <br /> CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE <br /> CA 955zo io _ 36s, - 753 <br /> TYP OF BUSINESS. 2 DISTRIBUTOR F—] 4 PROCESSOR N/Box A INDIAN EPA IDN 1101 TANK' <br /> RESERVATION or ❑ <br /> 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS. NAME(I-AST,FIRST) PHONE P WITH AREA CODE <br /> o�NI 90x'- 36-6-'S3 eP^ 9I6- - b ' <br /> NIGHTS'. NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> - Mcr O, Co <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �/� {10n ❑ CORPORATION 11LOCAL-AGENCYEl FEDERAL AGENCY <br /> �/ U1 a 0 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ling A - eles. (A 0036 >>93 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Scvwe us <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: I. ❑ I. Ill.❑ <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 E AGENCY R FACILITY ID N #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDA APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED n <br /> � BO 3ZO YES � NO ❑ L� '7 <br /> �a CNE K# PERYR AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> V <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. <br /> x v RM A(3-2-811) <br /> �C� <br />