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STATE OF CALIFORNP WATER RESOURCES CONTROL BOARD iz`P" ' '"f <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM _ �'m <br /> SITE (, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE `^<�.o y`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PER OSED SITE x <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE D <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bw to Mate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> L!!J.-!� �. .P '�-x ❑ RATION ❑ LOCAL AGENCY ❑ FEYRAL.AGENCY <br /> INOIVIOIIAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> �S cu !oh CA 95_i t* -7 3 <br /> TYPE OF BUSINESS. ❑ p RIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ ❑ TRUST RESERVLANDS ATION or ❑ (,((& rAT THIS SITE p� <br /> 1 GAS STATION 3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> rM do -U 75/.3 7 Sa, <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> ,Sc(ATL.e n e <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME cc �• CARE OF ADDRESS INFORMATION <br /> C�I L- <br /> MAILING or STREET ADDRESS ✓BO%I indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 13 pCJRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> as 1 <br /> MAILING or STREET ADDRESS ✓eO indicate ❑ PARTNERSHIP 13 STATE-AGENCY <br /> RPORATION 11 LOCAL-AGENCY ElFEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY 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. Er 11. ❑ Ill. ❑ <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 M JURISDICTION R AGENCY R FACILITY I R of TANKS at SITE <br /> 39FFFJ,,� q3 C) <br /> CU LOCAL ♦ ] H /Y ' APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERM PEmwoiArr8OVALDATIE- PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3�6— 3 oZ(lp YES ❑ NO ❑ <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: /yz) <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 /> ORM A(3-2-88) DATA PROCESSING COPY <br /> 4q -ql J <br />