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STATE OF CALIFORNIAN WATER RESOURCESCONTROL`abARD <br /> UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACI FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> NlA}trNA Fc-,O--IQ OA" 60Nsafvles <br /> ADDRESS NEAREST CROSS STREET ❑ PARTNERSHIP ❑ STATE A.GBIGY <br /> 31'lq S. E LOCAL <br /> FENEWAAM <br /> v 1:1 ROMOLIAOUNITY� <br /> CITY NAME STATE ZIPODE SITEPHONEN,WITHAREACODE <br /> ock o CA ct szo 209-9rs2—y6 2 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Bax if INDIAN EPA ID N <br /> 1 GAS STATION 3 FARM 5 OTHER RESERVATION 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 /> (/es <br /> NIGHTS'. NAME(LAST. IRST) PHONE N WITH AREA CODE NIGHTS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS�INNFORMATION <br /> NnTG_ a 1,ti L70Nsa(v(-S <br /> MAILING or STREET ADDRESS <br /> ox to indiWle 10 LOCAL AGENCY 3 PARTNERSHIP Cl STATE-AGENCY� ION Cl FEDERAL-AGENCY pJTx ?C ❑ NDIVDUALEl COUNTY-AGENCY <br /> CITY NAME <br /> STATE ZIP ODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e as <br /> MAILING or STREET ADDRESS ✓Box loinEicele ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WINCH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. 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 R JURISDICTION N AGENCY N FACILITY ID N M of TANKS Bt SITE <br /> CURRENT LOCAL AGENCY <br /> -FACILITY <br /> YIID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> t� I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOZS TRICT CODE BUSINESS PLAN FILED ❑ DAT/ D <br /> YES NO 1 <br /> CHECKS PERMIT AMOUNT SURCHARGE MOUNT FEE CODE RECEIPT SY� ./ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLYG <br /> FORM A(3-2-88) <br /> � 1.01 <br /> - <br />