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STATE OF CALIFORNbor WATER RESOURCES CONTRO BOARD <br /> UNDERGROUND STORAGE TANK PROGRAM = � o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ET-5`CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE i I <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAM / p CARE OF ADDRESS INFORMATION <br /> S5;(, .ti1Nv`.'t� <br /> ADDRESS q (� I /Y �� n ARE CROSS STREET, V 8 biCirge 0 PMITIG&V 0 STATEAGDO <br /> �` O I [ , I� L�� l rH//� V�KL/ p somimTIGN O LOM-AGS ❑ FEOE0.LL-AfiENGY <br /> CITY NAME ^ STATE ZIP CODE TE PHONE N,WITH AREA CODE <br /> Lf CA ab4 s <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑/d,,PROCESSOfl ✓Box if INDIAN EPA ID a <br /> ❑ ❑ [71 � <br /> RESERVATION <br /> LANDS GI ❑ N of TANKY / <br /> t GAS STATION 3FARM HEfl aAT <br /> of TANK's 1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST.FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> KtA,11% d o 0 <br /> NIGHTS: N' E( T,FIRST) PHON #WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE M WITH AREA CODE <br /> t AM <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ZI <br /> MAI NG or STREET ADDRESS I/Box to indicate 0 PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> TY NAM STBTE_ ZIP CODE PHONE N.WITH AREA CODE <br /> 11 TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS fp:t ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> D CORPORATION 0 LOCALsAGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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 WHICH ABOVE ADDREBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 11. ❑ 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 M FACILITY ID R R of TANKS at SITE " <br /> YE = = 10oa � � �-1 1610 <::� <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME d 1 PHONE R WITH AREA CODE <br /> S e✓ 37'7 -71 <br /> _ I <br /> Z. <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATILCOMCENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> dYES ❑ NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y BY: <br /> t <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3n2TB&)\ <br />