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ATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> o-' <br /> ,RM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> /J COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> E:1 7 P ANENTLY CLOSE <br /> MARK ONCL_Y ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> UARO,Aj Jlvm Gra <br /> NEAREST CROSS STREET ✓Bin b ideals [jPAAINEASHP ❑ STATE AGENCY <br /> ADDRESS <br /> IJ If ❑ COPMTON ❑MWLOCM!&ENG' ❑ FiDRAL-AGENCY <br /> VX�Jh ❑ INOAI ❑ CWNIY-__ <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> C7+r k+N CA 52 209 2- <br /> - S <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA 10 N _ a M TANK's <br /> ESE <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUSTYATION LAND$or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> - -62 65 <br /> NIGHT NA QRST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> uvrl <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION t <br /> / C/ A/ MC-1c, Derml <br /> MAILNNG o,STREET ADDRESS i,'Be.to indicate ❑ PARTNERSHIP 1:1 STATE-AGENCY <br /> 11CORPORATION 0 LOCAL-AGENCY C1FEDERAL-AGENCY <br /> Agemimo ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Lr —1 —� —_5000 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE N,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. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION If I' AGENCY M FACILITY ID K a of TANKS at SITE " <br /> EE = Ir — O El I Fal_ <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE F WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE TO <br /> Q YES ❑ NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N B _,/ <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-BB) / <br /> �r 't <br />