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STATE OF CALIFORNIA WATER RESOURCES CONTROAARD /z< <br /> FORMA": <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o <br /> COMPLETE THIS FORM FOR EACH FA LITY/SITE `'��•aa"-`" <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 SO CjO <br /> IV <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CD <br /> C'7 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> m I C,he,s,Q QO IL ( ack- �— <br /> ADDRESS , l (� NEAREST CROSS STREET <br /> ❑REET ✓Bailoir uN, El PARTNERSHIP ❑ STATE AGENCY <br /> ' ` U C �V U('�+ #DIV p�pLIDN CI COUNTY AGENCY ALAGENCY 11 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> Sfockiu, , CA u A095?v i9f <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR '/Box if INDIAN EPA ID # <br /> RESERVATION or #of TANKY <br /> ❑ 1 GAS STATION [:] 3 FARM �'S'OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> r-" i C)'1 c,_�A Po L l ac.l✓ qo� ZV?1DR) <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> M I PC) Gck �(1J <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> 1 I ��yT, ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM STAT ZIP CODE PHONE 4,WITH AREA CODE <br /> Ct�a�U Svc (40`6 --110 <br /> III. TANK OWNER INFO MATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,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. ❑ it. � 111.❑ <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# JURISDICTION At AGENCY# FACILITY ID If #of TANKS at SITE <br /> E9l E= 10101 1 E� I vv 1 0 16 <br /> CURRENT LOCAL AGENCY F CILITY ID It APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED r <br /> L-I I � YES NO I a i I g I <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> ^RM 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 /> 2-BS) <br /> DATA PROCESSING COPY IS <br />