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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD <br /> FORM ` ; <br /> (/ UNDERGROUND STORAGE TANK PROGRAM <br /> j_q_ <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° <br /> �� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> Cy O NrP <br /> [MARK ONLY ❑ 1 NEW PERMIT �3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONE ITEM p INTERIM PERMITEj PERMANE SITE A: <br /> 4 AMENDED PERMIT OR TEMPORARY SITE CLOSURE C. <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) v <br /> CO <br /> FACILI SITE N9ME OD <br /> rEPAID <br /> ESS INFORMATION <br /> /Yhryr—� /10 <br /> ADOgE <br /> �/, SS STREET ✓B.1 hale ❑ PAAINEASHIP ❑ 9ATEAGM <br /> V ✓✓` POAATIGN ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> CITY NAME INDIVIDUAL ❑ WUNTRAGENCY <br /> ZIP O .-A IT�E PHONE",WITH AREA CODE <br /> TYPE OF BUSINESS QE Ly, /5-2 ISTRIBUTOR 4 PROCESSOR ✓Box it INDIANbI GAS STATION 3 FARM 5 OTHER RESERVATION ar #of TANK'sOTRUST LANDS AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS:x NAM (LAST,FIRST) n PHONE#WITH AREA CODE DAYS. NA711(LAST FIRST) <br /> PHONIyftWITH AREA CODE <br /> NIGHTS: NAME A T,FIRST PH E# ITH AREA CODE NIGHTS. AME(LAST,FIRST) PHgN #WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) 31A <br /> NAME /) CARE OF ADDRESS INFORMATION <br /> •V <br /> MAILING Or STREET ADDRESS ✓Box to i,dl.ate Cl PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL 11COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> 777S 7A �E <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to in0icate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL.AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCYCITY NAME STATE ZIP CODE PHONE#,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. V IL ❑ 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 It AGENCY# FACILITY ID# #of TANKS at SITE <br /> lijil FFF�10 q a s D o a <br /> CURRENT LOCAL AGENCY FACILITY ID# AP� BY IN PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE R/1-'' PERMIT EXPIRATION ATE <br /> LOC ON CODE CIEN$JUSTRACT# SUPERV1 OR-DISTRICT CODE BUSINESS PLAN FILED DATE/FILED <br /> (�_' 2 ZQ YES NO 141 <br /> L 2 7 <br /> CHE <br /> Is.# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> wassassawassassamill <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 /> FORMA(3-2-88) c' <br /> DATA PROCESSING COPY J <br />