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STATE OF CALIFORNIkF WATER RESOURCES CONTRG..8OARD �~ <br /> 4\f, f4 <br /> f <br /> V <br /> FORM `i f, <br /> UNDERGROUND STORAGE TANK PROGRAM ="` <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m< o <br /> COMPLETE THIS FORM FOR EACH FAC /SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SED SITE I"A' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) (L OD <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> AD RESSLY11'/ Ad A-R-EIS-T CROSS STREET ✓ aG0,x PAWNENENIP ❑ STATE AGENCY <br /> g Y ' C7a Gt✓�„ e ✓LL Lk j"__— ❑ noN El LDna-AC❑ COIINIY-AGEN ❑ FEDENuACENcr <br /> NDNIDUAI ENC/ <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> c n CA 7Sdu I/ ye <br /> TYPED BUSINESS: p TRIBUTOR ❑ 4 PROCESSOR I/Box if INDIAN EPA ID a <br /> RESERVATION or /, //!! #of TANK'N <br /> III ❑ I GASSTATION 9 FARM ❑ 5 OTHER TRUST LANDS ❑ VG(l/ AT TRIS SITE 0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) _ HONE#WITH AREA CODE 0 YS'. NAME(LAST FIRST) PHONE a WITH AREA CODE <br /> .7 s c� - -Sys SA f mss\ <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA ODE <br /> 5- <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> - MAILING or STREET ACDDRaESS ✓ec ointlicDIVOUALale ❑ PARTNERSHIP 11STATE-AGENCY <br /> J v L7/-7 ❑ INP. ION 11 LOCAL-AGENCY Cl COUNTY-AGENCY <br /> FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONEA N.WITH� AREA CODE r�r --sY <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME S/ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Ro mtlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ 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. ❑ If. 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 B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID If If of TANKS at SITE <br /> 3 t 13 1 01 0 1 0101 <br /> CURRENT LOCAL AGENCY FACILIT 1 # APPROVED BY NAME PHONE N WITH AREA CODE <br /> f#ERMR NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LC.E <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3av �� YES NO 7- 7 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANI <br /> ED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'AP PLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(&2-SS) „A\V.'-'�`'Y)l�\V�Y_ DATA PROCESSING COPY <br /> DW <br />