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STATE OF CALIFORNI, WATER RESOURCES CONTR"BOARD <br /> r <br /> UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m o <br /> "r COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 2K7GHANGE OF INFORMATION PERM NTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> CA <br /> I.FACILITY/SITE INFORMATION &ADDRESS —(MUST BE COMPLETED) N <br /> FACILITY/SRE NAME CARE OF ADDRESS INFORMATION <br /> .� L la o(.%e le. <br /> ADDRESS ^� � N EST CROSS STREET ✓&ab#dnb ❑ PAAINB'6NP ❑ SEATE,IGENor <br /> 6.2 CY NDA WNL 11 NW46MCY Ll LomAwv ❑ FlIEV AGEN <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA elmg*c— <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box IT INDIAN EPA ID N poi TANK'S <br /> ❑ 1 GPS STATION ❑ 3 FARA 5 OTHEfl TRUSTT LANDS RESERVATION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> y3 2 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> c dd1� - 6z- z <br /> II. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ed4.l.� ie, <br /> MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION <br /> El ❑ FEDERAL-AGENCY <br /> 53 +� INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> %-0C_CL 7TH!-59-/72 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Saw)c as <br /> MAILING or STREET ADDRESS ✓Boxtoindlcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 110 III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> I APPLICANT'S NAME(PRINTED B SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# AGENCY# FACILITY ID M M of TANKS N SITE <br /> M = = 101012-1XI0000 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#1111711 AREA CODE <br /> E-1-AUT 2 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED <br /> ;_3/go 4/20 YES ❑ No ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> FORM A(3 2-88) " S <br /> DATA PROCESSING COPY <br />