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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARDSa <br /> FORMW: <br /> m <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,- <br /> C'a lIFO RNP <br /> COMPLETE THIS FORM FOR EACH FAC fTY/SITE <br /> MARK ONLY ❑ <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY D SI a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME f GY"vC) CARE OF ADDRESS INFORMATION <br /> ADDRESS vv NEAREST CROSS STREET -v/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ C551i ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> -7/ S .U`vej ��� �Z CrNDIVIDUAL ❑ COUNTY-AGENCYC� /` STATEP CODE SITE PHONE# WITH AREA CODE <br /> CITY NAME CATYPE OF BUSINESS: 2 IBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> RESERVATION or ❑ ��- AT THIS SITE1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDSEMERGENCY CONTACT PERSON(PRIMARY) EMERGNTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) ,.�, <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> e Groof lllQm -83B�dYb <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> S G.✓�-Q <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> 6v I-e <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP STATE-AGENCY <br /> ❑ <br /> p6PORATION ❑ LOCAL-AGENCY ElFEDERAL <br /> INDIVIDUAL El COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> Gdhiuve <br /> MAILING or STREET ADDRESS ✓Box t dicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> ❑ PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE It,WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(7)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 /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID #of TANKS at SITE <br /> NT AGENCY FACILITY ID# _ <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT NU <br /> DATE FILED <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS N FILED NO <br /> 3�ioFEE CODE YES <br /> � RECEIPT# BY: <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT <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 /> 1 FORM A(3-2-88)` 0 <br /> V v G DATA PROCESSING COPY <br />