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STATE OF CALIFORNlk WATER RESOURCES CONTROttOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION f <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE c <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 1ne o OF +D <br /> ADDRE NEAREST CROSS REST ✓N@b Mpk ❑ IP ❑ FEDERLGPNL4 <br /> ,. 1_ ❑ flN80MilON '- LOCAIRGENf.Y ❑ FEOEPPIABBH,Y <br /> (-1 (p--) NQmmef- Ln �� L(I�6" ❑ INDIVID caNn-nc�NY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> S+ocj-+ar. CA LAe'ly 1 209 951 -1zi% I <br /> TYPE OF BUSINESS ❑ 1:12 DISTRIBUTOR 4 PROCESSOR ✓Boz if INDIAN EPA ID N If of AT TANK'TE <br /> F-1 1 GASSTATION 1:1 3 FARM b l <br /> OTHER RESERVA ION or ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> k 6-n <br /> NIGHTS: AME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAMF I e "T) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF Apg�r ESS INFOR TION <br /> Cl OF S1-Oc�k+Dr� �1 1�iornk <br /> MAILING or STREET ADDRESS K"A .31 O� ✓Box to indicate EQ PA�RTNERSHIP ❑ STATEAGENCY <br /> J � G �__ 1 J,,, ❑ CORPORATION 4T-LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> L{ZNj <br />