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y <br /> - I <br /> STATE OF CALIFORNIkr WATER RESOURCES CONTRdBOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 o <br /> 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 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACIL ITV/@TE NAME CARE OF ADDRESS INFORMATION <br /> n> wcN N NJ Weiv rl^/ <br /> SII ADDRESS �Fs NEAREST CROSS STREET ✓2 udm 0 PARTNEPSHIP 0 STATE AGENCY <br /> Hca4n ❑ GGAPGRA1ON ❑ LOCAL-AGENCY ❑ FEDERAL <br /> C N011lllu I 0 C00TYAGENCY <br /> CITY NAME STATEZIP CODE SITE PHONE N,WITH AREA CODE <br /> N CA 2dh 207 - e//7 -2271 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ ❑ RESERVATION or /��/♦�� /�� #oll TANK's <br /> 1 GAS STATION 3 FARM E<5 OTHER TRUST LANDS ❑ VE I,,- ' AT THIS SITE ' <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 /> N I►.� N o --/W-2--171 UKN <br /> NIGHTS: NAME(LAST,FIRST) P14ONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> U � I <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SAI-AC AS T <br /> MAILING or STREET ADDRESS ✓Box to intlicate C 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 CARE OF ADDRESS INFORMATION <br /> SAME AS <br /> MAILING or STREET ADDRESS ✓Box tointlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <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. & —_ 11. ❑ TIL❑ <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* JURISDICTION R AGENCY N FACILITY ID N M of TANKS at SITE <br /> I 0Ol / ? zlegOD <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> ENIA � <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIQN CODE CENSUiiTRACT NO SUPERVISOR-DISTRICT R-DISTRICT CODE BUSINESS`P S N❑FILED NO ❑ E F ED� • ' <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT0 By: ,(✓j• <br /> I <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 ON <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />