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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': a i <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONo; l o <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION NTLY CLOSED SITE N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I LJ-'3 W <br /> 0 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> FACILITY/SITE NAM /` CARE OF ADDRESS INFORM IpN cc <br /> ADDRESS l/.•O- NEAR CROSS?STRE�FT�E:A/1F— ✓BMI.Mcik ❑ PARTNERSHIP ❑ STATEAGENCY <br /> 0P'ORRALDR °o LOCALAGE0 FEDERALAGENCY <br /> CITY NAME STATE IP W �/ SITE PH9=E A.WITH AREA CODE <br /> CA 0 74r- <br /> TYPE OFBUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> n�T 1 GAS STATION 3 FARM 5 OTHER RESERVATION or �/ M of TANK's <br /> ❑ ❑ TRUST LANDS ❑ A /r AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: AME(LAST,FIRST) PHONE N-1TH AREA CODE DAYS: NAME(LAST.FIRS ��#WITH AREA CODE <br /> ALk, <br /> NIG TS: NAME(LAST. STI 3RHO p ITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Jr S S <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME V N CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME ET^ *-- CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 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 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY# CILITY ID If - M of TANKS at SITE <br /> D, 3 4 v o <br /> CURRENT LOCAL AGENCY FACILITY 1 N T APPROVED BY NA PHONE N WITH AREA CODE <br /> PERMIT NUMBER J(GP/ERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TgBCTJIO SUPERVISOR-DISTRICT CODE BUSINESS SN FILED NO FRLED i 4r, <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RE IS /BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASI(1)OR MORE TANK PERMIT FORM B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br /> � E!f, <br />