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a <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROROARD <br /> 9E�� lM1f <br /> A <br /> FORM A% UNDERGROUND STORAGE TANK PROGRAM <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 0 w <br /> W <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) CA <br /> 4 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> /n� <br /> ADDRESS NEAREST CROSS STREET ✓gwleiMCra ElPARTNEASNIF El STATE AGENCY <br /> 33�Y LTIyJPPpRAT10N ❑ LOCALAGENLY ❑ FEDERAL AGENCY <br /> LI I\CCS) ❑ INDIVIDDAI ❑ AON AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> C CA Q!S,)L 20i q_4,6 <br /> TYPE OF BUSINESS'. 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box if INDIAN EPA ID p <br /> RESERVATION Or ❑ M of TANSY <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS \/ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) (7 � PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> Qi 4Yllrc , I�p�ll .1i qq o 7 <br /> NIGHTS: NAMlE I(LAST,FIRST) PHONE B WITH AREA CODE NIGHTS'. NAME(LAST FIRST PHONE#WITH ARE CODE <br /> PI}yyr: be✓v <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q r�.1L QJ <br /> MAILING or STREET ADDRESS ✓Be.to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE b,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> /Y`A Q�] <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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: Lv I. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCY N FACILITY ID 8 M of TANKS at SITE <br /> 3qI o I C --I il<�z -\ © ao <br /> CURRENT LOCAL AGENCY FACILITY ID N /'1 T OC k APPROVED BY NAME PHONE Jr WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TR2AGCT7k� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED /. <br /> b ) a ..J Dv d_o YES NO I-1()�n I <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 /> 1 FORM A(3-2-B8) / <br /> DATA PROCESSING COPY 0 (\J <br />