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STATE OF CALIFORNHt WATER RESOURCES CONTROdBOARD a <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM <br /> Sig FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONCOMPLETE 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 ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE $Q <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) to <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> e ft <br /> AD r-/� NEAREST CROSS STREET ✓B�i to iM.1h, 11 PARTNERSHIP El STATE AGENCY N <br /> D I I "� ❑/NORIVIpURL� ❑ COUNTYAGENCY <br /> 0 LOCAL AGENCY FIFEOEAAL-AGENCY <br /> 00 <br /> CITY NAME IFSTATE ZIP CODESITE PHONE#,WITH AREA CODE F1 <br /> S L _ <br /> CA ? a cc,< <br /> TYPE OF BUSINESS. ❑ p DISTRIBUTOR 4 PRO SSOR Box if INDIAN EPA ID p <br /> ❑ I GAS STATION ❑ 3 FARM THER <br /> RESERVATION or <br /> ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> AIA <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> nn -t es <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ,�L ( �j ❑ CORPORATION ClLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 7 1 Kou SG r• ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Sic) c- l:iv C/i 1 R 6ao 51 1 IA <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Sgirne. 4S r <br /> MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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. ❑ I. ❑ 111.❑ <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# JURISDICTION# AGENCY# FA _ #of TANKS at SITE <br /> F3_ b v a� 3 ,�_ _f1 0 0 10 1 0 <br /> CURRENT LOCAL A V FACILIfy ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> ( e <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> OCATION CODE CENSUS rCTM SUPERVISOR-DISTRICT CODE BUSINESY PLANFILED <br /> NC DAT FILED <br /> � �7 <br /> PERMITAM T SURCHARGEAMOUNT FEE CODE RECEIPT If BY: <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 INFDDD///;;;RRR1IIATION ON <br /> FORMA(3-2-88) 11')� <br /> `/ DATA PROCESSING COPY ..1 j1ll <br />