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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': 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 1�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE y <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) l o <br /> FACILI /SITE NAME CARE OF ADDRESS IN ORMATION <br /> \ Q <br /> Qh 'F L <br /> ADDRESS NEARESTLCROSSS�TREET <br /> PORTte ❑ LOCAL AGEN ❑ STATEAAGENNCY (Vst, ute ❑ PART RSHIIP ❑ FEDESTA7EAENDaa VIDUAi �'fAUNiVAGENCYGIIY NA E STATE SITE PHONE a,WITH AREA CODE 1'WyA <br /> CA SYs�- <br /> TYPE OF BUSINESS2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA O a X of TANK's <br /> ESE❑ I GASSTATION ❑ 3 FARM kr OTHER TRUSTY <br /> ATION LANDS o ❑ � AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAM (LAST,FIRST) PHONE a WITH AREA CODE DAYS MEµ�ST FIRST) PHONE a WITH AREA CODE <br /> 0 20 - y - 1 -z�-�602- <br /> NIGHT NAME(LA .FIRST) PHONE a WITH AREA CODE NIGHTS. NAME(LAST FIRS PHONE a WITH AREA CODE <br /> ch cr, Kew o - z3 s vr\ e� <br /> II. PROPERTY OWN9R INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME � . CARE OF ADD ESS INFORMATION <br /> h J G C ttit <br /> MAILING or STREET ADDRESS ✓Be.to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ OCAL-AGENCY ❑ FEDERALAGENCY <br /> y f Z ) foe ❑ INDIVIDUAL COUNTY-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF OGRES FORMATION <br /> MAILING or STREET SS Y/Box to indicate ❑ PARTNERSHIP a❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ CAL-AGENCY Cl FEDERAL-AGENCY <br /> f ❑ INDIVIDUAL COUNTY-AGENCY <br /> GIN NAM STATES /N ZIP CODE �Q PHONE�O f�T�AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS ��/(J� <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 K JURISDICTION If AGENCY IN FACILITY ID N N of TANKS at SITE <br /> OO 1 I 1016101 / 1 <br /> CURRENT LOCAL AGE CY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 23 a �i/1 YES NO <br /> CHECK N PERMIT AMOUNT(/ SURCHARGE AMOUNT FEE CODE RECEIPT M 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 /> FORMA(3-2-88) <br /> `� DATA PROCESSING COPY �� <br />