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STATE OF 'CALIFORNII WATER RESOURCES CONTROL BOARD <br /> FORMA': <br /> '"`` ;•'e <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> � > ' <br /> FACILITY/SITE, INFORMATION and/or PER APPLICATION <br /> 0 <br /> COMPLETE THIS FORM FOR <br /> R EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEM ❑ 5 CHANGE OF INFORMATION �p€RMANENTLY CLOSED SITE <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT <br /> 0 6 TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) O 00 <br /> FACILI ITE NAME '-4 W <br /> CARE OF ADDRESS INFORMq N <br /> ADDRESS r ,� <br /> G / }'1 NEA EST CROSS KR ET <br /> /�„-' — I rt14TO ❑ PARTNERSHIP ❑ STATEAGEND <br /> CITY NAME Lc_ CORP OAAi10.N ❑ LOCApgGENCY ❑ FEDERAL AGENCY <br /> STATE <br /> ✓ lr <br /> ( � ❑ INDIVIDUAL ❑ COUNttAGENCY <br /> L �cUL <br /> CA <br /> SIT PHONE P.WITH AREA CODE / <br /> TYPEOFBUSINESS: 02 DISTRIBUTOR 4PROCESSOR <br /> Bax if INDIAN EPA ID # Q <br /> E I GAS STATION D 3 FARM FM7 ;QTW RESERVATION or <br /> TRUST LANDS ❑ - #al TANKS <br /> EMERGENCY CONTACT PERSON(PRIMARY) ATTHIS SITE v/ I <br /> DAYS: NA (uST.FIRST) <br /> EMERGENCY CONTACT PERSON(SECONDARY) �./ <br /> PHONE Pt WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ./ I I ^^\ PHONE N WITH AREA CODE <br /> NIGHTS: NAME( T - <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> UA <br /> ( /� CARE OF ADDRESS INFORMATION Q <br /> - <br /> LINGO,STREET ADDRESS (�(�// /� /� ��1 �°' �Al/YIA IJ�..�� <br /> VA! �(J�� .�G CORPORATION 0 PARTNERSHIP ❑ STATE-AGENCY <br /> CITY NA <br /> ❑ INDIVIDUAL ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ COUNTY-gGENCV <br /> ckkvlSTgT ZIP CODE PHONE E WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> J;R <br /> NFORMATION <br /> MAILING o,STREET ADDRESS (Ja,[J <br /> ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> N ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ COUNTY-AGENCY <br /> ZIP CODE PHONE p,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. II. 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 8 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COOOU�N/T—Y## JURISDICTION# AGENCY# <br /> FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AG CY FACILITY ID# <br /> APPROVED BY <br /> ^ AME PHONE#WITM AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> LOCATI C CENSUS TRACT# SUPERVISOR-DIST CT CODE BUSINESS PLAN FILED `, SG <br /> p^1L lu�V, L DKII <br /> ED <br /> CMECKM YES 0 NO <br /> PERMITAMOUNT SURCHARGE AMOU <br /> FEE CODE flECEIPT# <br /> 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(3-2-68) . <br /> DATA PROCESSING COPY <br />