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V� - � <br /> ,.I"�f l�. 3.` m,�°''ry- .„r-. y . f'v1YS•'4:—i'Tx P,,, ;y. ''iti. <br /> n nJ <br /> STATE OF CALIFORNM WATER RESOURCES CONTRdtBOARD o, <br /> f <br /> i <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE l / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT 112<CHANGE OF INFORMATION ❑ 7RMA�N, YCLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] P 6 TEMPORARY SITE CLOSURE / , Z <br /> IO <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FAN/SIT NAME CARE OF DRESS INFORMATION <br /> c�J u A N <br /> ADDRESS N EST CROSS STREET ✓Bonbroote ❑ PAATNUMP ❑ STATE AGE* <br /> L ❑ AATDN ❑ LOCAL AGEN Y ❑ FEGDLALAGB Y 00 <br /> /r te NGmoL' ❑ coax acENc <br /> CITY NAM D STATE ZIP�OyE��O ITEPH L3/WITH AREA CODE <br /> s-OgO <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑I PROCESSOR R-/BOX 0 INDIAN ESERVATION or EPA ID p /T7JJJJ!( Y <br /> #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ A ATTHISSITE OJ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DA Y$: NAME(LAST,FIRST)6 H N7#WITH AREA CODE DAYS: NA (LAST,FIRST) PHONE p ITH AREA CODE N /4 S S A <br /> NIGHTS: NAME(LA FIRST) E#WITH AREA CODE NIGHT$y E(LAST,FIRST) PHONF�JI fJfTH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF DDRESS IN FORMATION <br /> MAIL I o STREET ADDRESS ✓Box to indicate 1:1PARTNERSHIP ❑ STATE-AGENCY <br /> a❑ CORPORATION El LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY N&ME J STATE ZIP CO E]I PHO #WITH AREA CODE <br /> sA1 <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NACARE OFADDRESS INFORMATION <br /> ME <br /> A Iiii <br /> MAIL rCREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> A ❑ BORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Ab ®/INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY A y STATE ZIP COD PHO p,WITH AREA CODE <br /> � � 6 <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. 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# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> ® = = I 003, 3 ,-da 10100 Ill <br /> i <br /> CURRIDIT LOCAL AGENCY FACILI ID# APPROVED BY NAME PHONE If WITH AREA CODE <br /> QSE z <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR•DWMICT CODE BUSINESS PLAN FILEDOf LED fi <br /> YES NO C] 6 7 VT <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If B c rJ <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 /> FORM A(3-2-58) <br /> DATA PROCESSING COPY ✓/ <br /> I <br />