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STATE OF CALIFORNIA WATER RESOURCES CONTROL !sEP'fie. <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM AJ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 " <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ' !- ' C0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> F �- -ft' i <br /> ADDRESS ^ NEAREST CROSS STREET ✓Box.to recce ❑ PARTNERSHIP ❑ STATE AGENCY <br /> E3 CORPORATION ❑ LOCALAGENCY ❑ FEDEAAL-AGENCY <br /> ❑ INONIOUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE O SITE P ONE a,WITH AREA CODE <br /> l ^ C O 9 `. 73 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER RESTRUSTVLANDIt of TANK's <br /> SG ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> ct r r � r r c4 (;I, 3 <br /> NIGHT$'. NAME( T,FIRST) PHO p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 3 fie, <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME / CARE OF ADDRESS INFORMATION <br /> S 4�m.L ,S'1 �2 <br /> MAILING or STREET ADDRESS I/Box t.,r icale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> C 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 /> S a,,A.E GZO <br /> MAILING or STREETADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE it 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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE <br /> 39 DDS = de 101 <br /> CURRENT LOCAL AGENCY FACT IT D# APPROVED BY NAME PHONE#WITH AREA CODE <br /> F Co 17 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Qm <br /> YES NO <br /> CHECK Al PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> FORM A(3-2-88) (� <br /> DATA PROCESSING COPY �J <br />