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v.. .�h!t ...,.. • f. .a. <br /> STATE OF CALIFORN1'X WATER RESOURCES CONTROL BOARD <br /> FORMAT: <br /> SIT UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORM <br /> ONE ITEM 2 INTERIM 7 PERMANENT LOSED SITE❑ C <br /> ❑ PERMIT ❑ q AMENDED PERMIT [:]6 TEMPORARY SITE CLOSURE /' O •O <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) (O c' <br /> FACILITY/SITE NAME FfzW CARE OF ADDRESS INFORMATION W <br /> ADDRESS5�5Im <br /> I <br /> �1 NEAREST CROSS STREET ✓Bpa loirdicaN 11 PARTNERSHIP ClSTAiE-AGENCY <br /> ❑ Q]F`�IiATIDN 0 LOCAL ❑ FEDEMLAGENCY <br /> CITY NAME 111DII 0 COUNTYAGENCY <br /> • STATE ZIP CODE SITE PHONE A.WITH AREA CODE <br /> TYPEOFBUSINESS ❑ 2_ l RIBUTOR ❑ 4 PROCESSOfl ✓Box if INDIAN EPA D PA AOT 33 —AAO <br /> ❑ 1 GASSTATION FARM ❑ 5 OTHER RESERVATION oraof TANK'S <br /> ❑ <br /> TRUST LANDS IN �"�� AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAPNAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> r� u�vn C.�ur eS 209 33H- ;Lo?' <br /> NIGHTS'. NAME(LAST FIRST) �� PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> `\I q-ll <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME SA 9 iCARE OF ADDRESS INFORMATION <br /> MAILING or SYREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 11 CORPORATION 0 LOCAL-AGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH ARFA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STR ET ADDRESS ✓Box Io ie0icate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> 'CHECK (1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. ❑ 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# JURISDICTION AT AGENCY# FACIL If of TANKS at SITE <br /> aan io dna / <br /> CURRENT l0 AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1=RE1�� 1 <br /> PERMIT NU ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT ON CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a3 A x a, D-1YES ❑ NO ❑ t <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT It 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 INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> M a k 1 -P� DATA PROCESSING COPY <br />