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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> ZZx�� .lyF <br /> FORM 'i UNDERGROUND STORAGE TANK PROGRAM ..., m^ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ® t o { <br /> T COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION VLPERMANENTLY CLOSED SITE F+ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /5 ry <br /> l 4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME I CARE OF ADDRESS INFORMATION <br /> � � arbaru s o IlflaJ <br /> ADIDIRESS <br /> Koff. <br /> /� NEAREST CROSS STREET ✓NoxbnJ✓sk ❑ PARTNERMfiIP ElSTATEAGENCY <br /> l U W. Gt�a►4loe- Ol 4WCGfPDRAMON ❑ LOCAL�AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 13COUNTYAGENCY <br /> CITU NAME STATE ZIP CODE SITE PHONE At WITH AREA CODE <br /> CA w, <br /> TYPE OF BUSINESS: p DISTRIBUTOR `❑ 4 PROCESSOR ✓Box if INDIAN EPA D 4 G�1J U�1 v <br /> ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ESERVATION or ❑ N PI TANK'N <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAV$ NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> sort 1 2041 Di <br /> NIGHTS: NAME(LAST.FIRST) PHONE p WITH AREA CODE NIG <br /> Ig NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> (kKN K N <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION I <br /> / Wff6' mSa%j /,) <br /> cd <br /> MAIL UNG or STREET ADDRER° I/Box to adicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> p OF1CORPORATION ElLOCAL-AGENCYElFEDERAL-AGENCY <br /> 5 7,/6 OK INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATLl/-' ZIPPHONE N,WITH AREA CODE <br /> �� <br /> �jor-, - <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SAM C- AsrL <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <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 MUNICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N k of TANKS at SITE <br /> 3 = = 10 10 1 -2I= 10 16 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED 8Y NAME PHONE N WITH AREA CODE <br /> A41D I C 1H II <br /> PERMIT NUMBE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TTli SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 2 , ao YES [—] NO ❑ �/ 8 rT <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <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(3-2-68) <br /> A'� DATA PROCESSING COPY 15 <br />