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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD ;r« 'e <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM <br /> o <br /> SITE�&7 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE .o�" I[7 <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERM gLOSED SITE IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUREcn <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) co <br /> NI <br /> FACILITY/SITI.U,AME CARE OF wDRESS INFORMATION <br /> A�1 <br /> ADDRESS NEARS TCROSS STREET ✓BOF Io kale E7 PARTNERSHIP ❑ FATE AGENCI <br /> PAT/7 b �+ ❑ NGIVDUALIGN ❑ COUNTY AGENCY FEGERALAGENGY <br /> CIiSTATE ZIP oDf Z SITE PHO E p.WITH AREA CIO/DE <br /> Lddle:p CA <br /> TYPE of RUSHES ❑ STRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID H S ,/~ �� <br /> ❑ I GAS STATION 3FARM ❑ 5OTHER TRUSTYLANDSo ❑ ATTHISSITEOO <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMER ENCY CONTACT PERSON(SECONDARY) <br /> DAYSNAME(LASTAFIRST PHONE#WITH AREA CODE DAYS. N E(LAST.FIRST) PHONE N WITH AREA CODE <br /> SA � <br /> NIG TS: NAME(LA FIRST) PHO E p WITH AREA CODE NIGH AME(LAST,FIRST) PH N N WITH AREA CODE <br /> 40 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box o in0icate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ili. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> VA T <br /> MAILING or STREET ADDRESS ✓Box to intlioate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <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: Lz it. ❑ 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 /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# At of TANKS at SITE <br /> Ob 14 T�- u D 10 lvl <br /> CURRENT LOCAL AGENCY FACILITY ID# APP O ED BY NAM PHONE#WITH AREA CODE <br /> at 712- <br /> PERMIT NUMBER PERMIT APPROVAL DATE P RMIT EXPIRATION DATE <br /> LOCAT NCODE CEN��ACT# SUPERVISOR-DISTRICT CODE BUSINESS ISN❑FILED NO / DATE FILED Z <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT +�rj l{ ('fj—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(3-2-88) <br /> G-N-;Ll SC DATA PROCESSING COPY j <br />