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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM SAI: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> R COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"► <br /> ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE1 F-+ <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> l)eP'Icl'-SOIJ f C INCA <br /> ADDRESS O ENURESTESTREET ✓ W 0 PAIRNEASHIP 0 STATE AGENCY <br /> DI(4 'T«+ ❑ LOCALAGENCY ❑ ROEMLAGENCY <br /> ❑ IN"WAt 0 couNlYAGENCY <br /> CITY NAME DE SIT PHONE#,WITH AREA CODE <br /> �SCPVLOuJ S3 Z c; 9 - 00 <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID N <br /> ❑ i GAS STATION F-13 FARM ❑ 5 OTHER I ESE <br /> TRUSTVATION LANDS or ❑ N of TANK'# <br /> AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(1-AST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> CILSOr, _MV7 pr;- <br /> NIGHTS: NAME(IAST,FIRS P ONE N WITH AREA CODE NIGHTS'. NAME(LASTFIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1FW S a- g. E7z IC d <br /> MAILING or STREET ADDRESS -/B.toiedicala ❑ PARTNERSHIP 0 STATE-AGENCY <br /> c / 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> �`- PICL DFA_ 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> L CA ?3 83k-ay4S <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 1:1 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE W,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. Il, ❑ Ill.❑ <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 B JURISDICTION N AGENCY A FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCA AOE�NCYT�FACILITY IDNAPPROVED BY NAME PHONE N WITH AREA CODE <br /> G Ic IttD <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONCO E CENSUS TRAC((TAAN,, SUPERVISOR-DISTRICT C DE BUSINESS PLAN FILED DATE FILED py/ <br /> / oZ 3. XL/ �- YES [_] <br /> NOCj <br /> I S p Cl <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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(3-2-88) <br /> �.. DATA PROCESSING COPY a < <br />