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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM ' '• <br /> SITE FACILITY/SITE,UNDERGROUND STORAGE TANK PROGRAM <br /> INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE r <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PERM LOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT4 AMENDED PERMIT —4 <br /> ❑ ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) A <br /> FACILITY/SITE AME . CARE OF ADDRESS INFORMATION co <br /> +I <br /> ADDRESS ,( � �j�y Q, (]��� IEPAID <br /> CROSS STREET <br /> /`/ r �•C."" c+ L -IBM ❑ V/MNEHSIIP ❑ SfAiEAGEIVLY <br /> a1N111 Q IIx,V-AGENCY ❑ FEDERALAUENCY <br /> CITY NAM 1177 INDNIDUL ❑ COUNIKAGBCY <br /> D E PHO R 0 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓BOX#INDIAN❑ 1GASSTATION ❑ 3 FARM OTHER RESERVATION or / MMTA 8 DTRUST LANDS ❑ ATT <br /> TNIB SfrEC/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> S: NAME(LAST FIpST) PHO E#WITH AREA(CODE DAYS: rME(UST,FIRST) PHONE ITH AREA CODE <br /> _ihd1jAek M-1 <br /> clm <br /> NIGHTS: NAME(LAST,FIR P ONE#WITH AREA CODE NIGHT$: AME(UST,FIRST) PMO W <br /> ITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION ADDRESS- (MUST BE COMPLETED) /•V{ <br /> NAME CARE pXRESS INFORMATION <br /> MAI G or R}'jq ADD SS/ ,L��✓/ByOX la inEicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> # LI INDIVDUALION COUNTY-AGENCY <br /> AL-AEl FEDERAL-AGENCY <br /> CITY NAME� STATE ZI PHO k, TH AREA ODE I <br /> X36 � it <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME S CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS - - _ ✓Box to mdlcale ❑ PARTNERSHIP ❑ STATE-AGENCY Ifl <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 11 INDIVIDUAL ElCOUNTY-AGENCYCITY NAME STATE ZIP ODE PHONE N.WITH AREA CODE <br /> 1 <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. ❑ IL 111,❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> [ffl I 1SDl S oc) oo <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMITUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 1 <br /> LOCATION CODE CENSUS TRACT�0 SUPERVISOR-DISTRICT CODE BUSINESSPLAN❑FILED NO �DATE D7 11/17 <br /> 1 <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* 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 /> FORM A(3-2 <br /> DATA PROCESSING COPY <br /> -- FORM B(6-29-651 THIS FORM MUST B U m <br /> DATA PROCESSING COPY <br />