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_ OF CALIFOR19A WATER RESOURCES CONT91L BOARD <br /> �P <br /> A ' UNDERGROUND STORAGE TANK PROGRAM = <br /> i TEi:[_ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT, <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 5 r <br /> I, FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE ME CARE OF AD ESS INFORMATION <br /> n W�Y� Zl�L 'EYIR �n' ;NDEUk <br /> G rl <br /> ADDRESS ( n NEAREST CROSS STREET I/BUM 0 PARTNERSHIP 0 SATE AGENCY <br /> n ' ��n r r�-e�' �C� O O Imu�NryYacwcY ❑ accNcr <br /> CITY NAME STATE ZIP ODE SITE PHONE N,WITH AREA CODE <br /> LOCA CA �45 q a 09 70 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR '-/Box 4INDIAN EPA ID N <br /> ❑ 1 GAS STATION ❑3 FARM �tRHER #of TANK <br /> TRUSRESETYLANDS VATION or ❑ AT THIS SITE (0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> I>en 7�Dma s <br /> ;to °I 3(p9 �0 <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> .l— <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> I'yLL a�_' J <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ,� ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE I PHONE N,WITH AREA CODE <br /> LOak 5 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS JBox to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ if. 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 N AGENCY N FACILITY ID p N of TANKS at SITE <br /> o I o I i FFF-41 <br /> C� <br /> CURRENT LOCAL AGENCY FACILITY IDN II ,,11rrll APPROVED BY NAME PHONEN WITH AREA CODE <br /> WV (.0 L <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATI$jPE CENSUS T�CTM SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED +Y <br /> L-J <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE YES ❑pECEIPTIND ❑ ��� IP �� <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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />