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ze'rYo, rMF I <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROLIARD <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o •1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c�"fOP��P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT �6TEMPORARY <br /> HANGE OF INFORMATION �07 RMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ SITE CLOSURE 4 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME(jpj �� (e (401 CARE OF ADDRESS INFORMATION <br /> /, <br /> ADDRESS I` S v <br /> 5. NEAREST CROSS STREET ✓ bMiple PARTNERSHIP STATE-AGENCY <br /> 0 a� WRFDRATION ❑ LDCALAGENCY ❑ FEDERAL AGM <br /> iNDWIDUAL ❑ CAIINtt A(ffNCY <br /> CITY NAME /1�( _(� o r STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR`I -/Box it INDIAN EPA ID N 7GS/!7/V/1 M of TANKY <br /> 5 OTHER RESERVATION or AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PH E ITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> MAT �G✓S S L �" <br /> NIGHTS: NAME(LAST.FIRST) PHOrr M WITH AREA CODE NIGHTS: NAME LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRES ✓Box CORP RATIIO ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ( O 6 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> ' CITY NAMEIMT ^at" STAT ZIP CODE � PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME _ U CARE OF ADDRESS INFORMATION <br /> � � <br /> MAILING or STREET ADDRESS ox to indlcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> I O t INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME / STATE ZIP CODE PHONE N,WITH AREA CODE 6 O <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. ❑ If. EV <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,X 15 TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION* AGENCY K FACILITY ID N N of TANKS at SITE <br /> 10161 111 TFT2l 101010 <br /> CURRENT LOCAL AGENCY FACILITY ID B� APPROVED BY NAME PHONE N WITH AREA CODE <br /> U . V S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES E] NO � 3 <br /> CHECK N PERMIT/AMOUNT {/ SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM 'B'APPLICATION(SI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> �0PA3�RS1 <br /> /U `. DATA PROCESSING COPY A� <br />