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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a ?"` <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM =` t o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : <br /> COMPLETE THIS FORM FORE CHF CILITY/SITE "'��F�'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT5 CHANGE OF INFORMATION YCLOSEDSITE F� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACIUTY/SITE NAME CARE OF ADDRESSI ORMATIIONN <br /> ADDRESS ) NEAREST CROSS STREET I ✓IkabYtlab ❑ PARTef RaiF SGTEAG.B <br /> 31 � o � oo RGONAGBOi0-:7 � 33 ° � <br /> CITY NAME STATE ZIP CODE SITE PHONE 9,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISMISWOR R ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST IANDS ❑ h AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) /� a p{ P�NE p}YITH A EA COD PAYS. NAME(LAST,FIRST) PHONF,Jt WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) /Wt_Nl. /vvnPHONEE#WITH AREA CODE NIGHT•SJ: NAQAMMEE((LAST,FIRST) PPHHONEEU##WWITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDR�FORMATIONI <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHI STATE-AGENCY <br /> g�� El CORPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY <br /> v ❑ INDIVIDUAL 11 COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE p.WITH CODE <br /> 7f� <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME 4- a/ <br /> CARE OF ADD- RE$S�INFORMATION <br /> MAILING or STREET ADDRESS V� ( /F -/Box to indicate Cl PARTNERSHIP JAS STATE-AGENCY <br /> `./ Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE PCODE PHONE 4,WITH VEA 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> Tr 16o 6) <br /> CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE N WITH AREA CODE <br /> AL 13 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT COiffDE BUSINESS PLAN FILED DATE FI D <br /> YES � NO 0 / 3// <br /> o W <br /> CHECK# <br /> ITHI <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTa BY: <br /> S FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION TREY <br /> A(3-2-SBt <br /> �" DATA PROCESSING COPY '� <br />