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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br />FORMA': UNDERGROUND STORAGE TANK PROGRAM <br />SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />0-1/ '-1/ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I13 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />FACILITY/SITE NAME <br />OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />-/ Box to indicate 0 PARTNERSHIP 0 STATE -AGENCY <br />MAILING or STREET ADDRESS <br />✓Box to indicate 0 PARTNERSHIP 0 STATE -AGENCY <br />rl�� <br />ISI <br />ADDRESS <br />CITY NAME <br />NEAREST CROSS STREET <br />✓Bae reir4care 0 PARTNERSHIP 0 STATE AGENCY <br />PERMIT EXPIRATION DATE <br />S? -C),- 2 q - -I <br />0 CORPORATION 0 LOCALAGBKY 0 FEOEML-AGENCY <br />3 �^ <br />J I <br />r Ave <br />' li r�� <br />X42 T <br />0 INDIVIDUAL Cl COUNTY.AGENLY <br />CITY INA <br />PERMIT AMOUNT <br />STATESTATE <br />ZIP CODE <br />FEE CODE <br />SITE PHONE N, WITH AREA CODE <br />L " <br />BY: <br />CA <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR <br />❑ 4 PROCESSOR <br />✓ Box it INDIAN <br />EPA ID p <br />S TANK'a <br />❑ 1 GAS STATION ❑ 3 FARM <br />❑ 5 OTHER <br />RESERVATION or <br />TRUST LANDS ❑ <br />AT THIS SITE ' <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS. NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />NIGHTS. NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAMECARE <br />OF ADDRESS INFORMATION <br />1 T' <br />� N <br />-/ Box to indicate 0 PARTNERSHIP 0 STATE -AGENCY <br />MAILING or STREET ADDRESS <br />✓Box to indicate 0 PARTNERSHIP 0 STATE -AGENCY <br />rl�� <br />ISI <br />0 CORPORATION 0 LOCAL -AGENCY 0 FEDERAL -AGENCY <br />0 INDIVIDUAL 0 COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIPCODE O N, WITH AREA CODE <br />PERMIT EXPIRATION DATE <br />S? -C),- 2 q - -I <br />III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME <br />palpej�j <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />-/ Box to indicate 0 PARTNERSHIP 0 STATE -AGENCY <br />N of TANKS at SITE <br />0 CORPORATION 0 LOCAL -AGENCY 0 FEDERAL -AGENCY <br />0 INDIVIDUAL 0 COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE PHONE It, 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: L ❑ IL ❑ 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 8 SIGNATURE) DATE <br />I nrAl AF2Fli IISF nPJLV <br />COUNTY K <br />JURISDICTION k <br />AGENCY* <br />FACILITY ID N <br />N of TANKS at SITE <br />CURRENT LOCAL AGENCY FACILITY ID N <br />APPROVED BY NAME PHONE K WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />CENSUS TRACT N <br />a3 a3 <br />SUPERVISOR -DISTRICT CODE <br />BUSINESS PLAN FILED <br />YES ❑ NO ❑ <br />DATE FILED n�-x <br />/ ` 0 <br />CH CKN <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPTN <br />BY: <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FOHNI -IT APPLICATION($), UNLESS 1 MI51$ A VMAMUC Vr aI1C 1MPVKMMDUR VRLl. <br />FORM A (3-2-88) <br />VW DATA PROCESSING COPY 14ONk <br />IV <br />0 <br />0 <br />CID <br />