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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM ' <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �= <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `�.o g�F• t <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMA ED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Ln <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) -� <br /> FACILITY/SITE NAA CARE,91 ADDRESS INFORMATION <br /> D. �>04.fi- <br /> ADDRESS NEA EST CROSS STREET 1/801 to nRipk ❑ LOCPARTNERSHIP ❑ FSIATEEDERAGENGY <br /> d\ (/�'/.�' -❑J J,BAPORATION ❑ COUNTY AGENCY ❑ FEDERALAGENCY <br /> INGIVDUAI ❑ COUNTY AGENCi <br /> CITU NAMESTATE ZIP CODE SITE PH E A.WITH ARE DE, <br /> CA <br /> 3 <br /> TYPE OF BUSINESS ❑ p TRIBUTOR ❑4 PROCESSOR -/Box if INDIAN EPA ID p <br /> RESERVATION or #of TANK'I <br /> ❑ 1 GASSTATION 3 FARM ❑ S OTHER TRUST LANDS ❑ ATTHISSITEOO <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAY$: NAME(LA lea+ `^�'.' PHONE p WITH AREA CODE DAVN ME(LAST,FIRST) PHI WITH AREA CODE <br /> S Q a �4 <br /> NIGHTSNAME(LAST F PH E N WITH AREA CODE NIG AME(LAST,FIRST) PHO N TH AREA CODE <br /> /Q s .\\77 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME , <br /> CARE OF ADDRESS INFORMATION <br /> ,.I/ 1. <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCYIN FACILITY ID# #of TANKS at SITE <br /> p alb 1 S' 3 1 00 100 <br /> CURRENT LOCAL AOENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE <br /> >c/3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTINCT CODE BUSINESS PLAN FILED D ILE <br /> 27-� �26 YES � NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT B . <br /> ITHIS FORM MUST BEACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL <br /> FORMA(3-2-88) <br /> ,V,V/ 'Amw DATA PROCESSING COPY �� <br />