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STATE OF CALIFOR 'P, WATER RESOURCES CONTR(,,_ 30ARD5 ..k;...11 <br /> P ,p <br /> FORMW: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFOR6t ATION and/or PERMIT APPLICATION ,�+`/ ° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 9rIFORN�P� <br /> 1 NEW <br /> 3 RENEWAL PERMIT CHANGE OF <br /> MARK f3FfLY 2 NTERIMRP IRMIT ❑4 AMENDED PERMIT 6 TEMPORARYSITE CLOSURE 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2� <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) r c� <br /> CILITY/SITE NAME <br /> i, 1 2, E OF ADDRESS INFORMAT� <br /> 195 <br /> ADDRESS _ r( REST CROSS STREET `� ('\o NEA Boz to indicate hRTNERSHiP ❑ STATE-AGENCY <br /> C � �t -�-� J/ ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY C.,,-I <br /> vat I✓'/ C:?' J:.� i'" ❑ INDIVIDUAL <br /> ❑ COUNTY-AGENCY - <br /> �cITY NAME �_ STATE FCODII ITE PHONE#,WITH AREA CODE <br /> l //c4-U CA 7 !/ <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # H r <br /> I—1 i r c rre, In, I� a c 1 RESERVATION or e #of TANK's <br /> u ,A TON u „,.ARh 5 OTHER TRUST LANDS ❑ y tt �j^ ^ <br /> I C,i,� i. 1 AT THIS SITE - <br /> EMERGENCY CONTACT PERSON(PRINNARY) PAER sENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> cJ 41111 ✓�Lli r,,j d_'1>:2t,.1' � /x//1&16 <br /> IGHTS: NAME(LAST,FIRST) PHONr N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> H. PROPERTY`' WNER INFORMATION & ADDRESS — (MIDST BE COMPLETED) <br /> ME CRE OF ADDRESS INFORMATION <br /> M61LING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> l/ 1' CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> NAME T TE CODE kIE#,WITH AREA CODE <br /> 21:0 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COI'llPL€TED) <br /> NAME OF ADDRESS INFORMATION <br /> ING or STREET ADDRESS �J�✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> f i / 7� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ''f'1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> 4NAME *S ,ATE ODE NE#,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. <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 /> fIRR0I.NT <br /> OUNTY# JURISDICTION# AGENCY# FACILITY ID# Pi� #of TANKS at SITE <br /> - E <br /> LOCAL AGENCY FACILITY ID 00 VIED BY NA - PHONE#WITH AREA CODE <br /> ERMIT NUMBERE/R�MIT APPROVAL DAT !EX-IT EXPIRATION DATE <br /> '7 G� <br /> LOFATION CODE M$US TRACT#" SUPERVf OR-DISTRICT CODE BUSINESS PLAN FILED - ILEO <br /> C�� YES NO � <br /> CHECK It PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING CO� <br />