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STATE OF CALIFO h WATEh RE6OURICE$ CbNThDL BbARD <br /> U) N *•iF�f •; ,,.. , i �pROORA• : � ; � OOUN� STONAOE fANIA�4RA O fIit ' t <br /> q <br /> to I <br /> SITE /9dILItMiTti iI�FOAMATIaN fii'id/oar 096-MITAPPLICATION <br /> , :F � eta <br /> b6M0LETI:TFii§00R' M 00D gACH PAc! /$ITE C�l1FOR <br /> 9 �JE1M PERMIT t.,. S gEN1 VIAL PEfiUIIT CHANGE r" <br /> MARK d1LY ❑ ❑ OF INFORMATION ❑ 7 PERMAN OSED SITE #V <br /> ONE ItEMN (—•—� 2 lN7EfiIM pERMl1 (—,,,� d A�IENb�E3 PERMIT 6 7WPOFi11RY SI.Tt CLOSURE <br /> !. ACi .., . <br /> LiTi�/S.I`i'� IN�Or�MAtiON�Aiyi?RES� � (lu�[1ST bE COMoLi=TED) , <br /> , 1 <br /> FACILITY/SrrE NAME y CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ oedrals ❑ PARTMERSHP ❑ STATE-AGUO <br /> CORPORATIar ❑ LOGLAGENCY ❑ FFl)Ewt-AGEMti f <br /> ,I. ., .i; ❑ IMDIYIUUAL ❑ (XI W-AGENCY <br /> CITY'NAME STATE 21P CODE SITE PHONE N,WITH AREA CODE <br /> c!c CA it 9 Saws -yb s� <br /> TYPE OF BUSINESS bISiRIBIi <br /> ❑ TOR ❑d ✓Boz if INDIAN EPA ID a l+ TANK's <br /> RESERVATION or 1 k of AT THIS SITE <br /> ❑ 1 GAS 5TAi10N . ❑3 f DiH R TRUST.LANDS, <br /> F_hiEAGENCY 6614tAC7 EMERGENCY CONTACT PERSON(SECONDARY) <br /> - DAYS: NAME(LAST.FIRST) " PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE.#WITH AREA CDDE <br /> n !1'r .. - ('s-3 SG <br /> NIGHTS. NAME(LAST,FIgST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> l <br /> ✓ 11. PRQPEOTY bWNkR.IN�6I%MAb6N B ADDRESS- (MUST BE COMPLETED) <br />,a NAMECARE OF ADDRESS INFORMATION <br /> vip <br /> MAILING or STREET ADDRESS j ✓ o indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL.-AGENCY p <br /> rl'(� ❑ INDIVIDUAL{y ❑ COUNTY-AGENCY <br /> k CITY NAME - STATE ZIR CODE - PHONE!E.WITH AREA CODE - <br /> I11. TANK OWN10% INPOMATioN 1 ADDRESS---.(MUST BE COMPLETIED) <br /> NA0 [CAI'I�ErOlj ADDRESS INFOiiMATION <br /> 5 h <br /> i <br /> MAILING or STREET ADDRESS - - to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL'fCOUNTY-AGENCY <br /> CITY NAME ZIP CODE PHONE N,WITH AREA CODE <br /> ' [ .tit•- -+ '. <br /> IV. LEQAL N0tIFI6ATIb ANIS 4� ANCA AbDftEft <br /> i A 1Nif 01"alb WA Alisrl M WOW At USER EUIi AND h N LkcAL 004iWi6i NiLLINc: L If. ❑ III.❑ <br /> c►iEdt CNI �i���dRl�Ib E _ ., <br /> fiNfS F60M WA§kttN 60__MOLEfb 60 90 AENALI tY OF�EN,IUAY ANb TO THE BEST OP MY KNOWLEDGE,IS tPUE AND CORRECT, <br /> I APPLICANT'S NAME{PRINttb+I SIDNAl'UREi DATE <br /> LOCAL AOENEY~USS �DNL : L. �.,. - <br /> Coijwi*li., .,Junibl� qN '_�i Acit�kv i1FAciL�fiY Ioi! #I o1 TANKS it SITE <br /> i T <br /> x CURRENT LOCAL A*Fktt PACILfi'Y ID Ti I; s c {k ,«11 APPROYEO ilr RAIAE PHONE II wryTH AREA CODE <br /> PERMIT?NUMiRER PEIifEIt APPMiDVAL DATE PERAilt b0istATION DATE <br /> LOCATION CODE CENBUti"ACT 8 TiUPENVISOtI-018TTIICt BODE flusiNEA8 PLAN)FILED DATE FILED! r <br /> e1�E§ ❑ NO ❑ ( 1J <br /> 4 CHECK# kkkit AiiDUf1T' q%r „AURcHAIiT;fE AlI10UNt FEE CODE_ ii RECEIT>T BY: <br /> THIS Fohm mutt BE AcMki klib it O UAft ii)6h MORS UNR khMit FORM B. OPLICATION1.06lAt IS A CHANaE Of SfTE INFORMATION ONLY. <br /> FORMA(3-2-88) ' <br /> � DATA IPIiDCk$SIbIQ CCoY <br />