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STATE OF CALIFORNIP WATER RESOURCES CONTRA ARD <br /> FORMA': y <br /> au f <br /> UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w r, I <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE `�<,.o �a <br /> MARK ONLY ❑❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERnMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE 1O75 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) Cn <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CD <br /> ADDRElSS / � NEAREST CROSS STREET ✓Box to irdicat¢ PARTNERSHIP 11 STATE-AGENCY <br /> L -3 �� /-'L-�N� ❑ CORINDPDIRIAIIGN O LOCAL AGENCY <br /> ❑ FENEBALAGENCY <br /> CITY NAME STATE IF CODE <br /> SITE PHONE p,WITH AREA CODE <br /> V`— ♦�-' CA 20s <br /> TYPE OF BUSINESS: p IBUTOR E]4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER TRUST ANDS TION or ❑ p of TANK'S <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE ft WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NA pEs <br /> CARE OF ADDRESS INFORMATION <br /> e Srtc�cL : H S <br /> MAILINC�igrS ^EET ADD R S ✓Box toindicate Pq RTNERSHIP ❑ STATE-AGENCY <br /> / �1 ("r` �rN�J ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME z �qSTAT ZIP CODE PHONE p,WITH AREA CODE <br /> 4?711S2os- <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL ElCOUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE a,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. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Of AGENCY# FACILITY ID If #of TANKS at SITE <br /> � 7L <br /> CURRENT LOCAL AGENrY FAC�I It ��� APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER // yyTT PERMIT APPROVAL DATE PER MIT EXPIRATION DATE <br /> LOC TION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDLNO [—] <br /> DATE FILED <br /> 3. 23 25✓ YES �CXECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPR . <br /> WTHIS 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 /> DATA PROCESSING COPY C <br />