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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMW: UNDERGROUND S R GRAM s'p�►' <br /> SIT FACILITY/SITE, INFORMAT ER APPLICATION 10 <br /> Tal COMPLETE THIS FORM FOR EACH FACIUTY/SITE <br /> YAIMf ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT E]5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE Fi <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> CD <br /> 1.FACiLITY/SITE INFORMATIONS ADDRESS—(MUST BE COMPLETED) <br /> FACt1TYe_ TI <br /> O '�orr -ROIW �= dauAe'C ab <br /> ADOTESS o E y � c�I M i i O❑ L ❑ JI AGM <br /> imwm4asa it Link <br /> STATE Zf CODE SITE PHONE N.WITH AREA CODE <br /> CA `15a�1 ( 20g) -7L59-3331 <br /> TYPE OF BIASI&W ❑2 DI Wff0R N PWXESWR ✓Boot A MID AN EPA ID N <br /> REst�1vAT1oN a r a TAa'acs <br /> f 13ASSTATION 3 FARM 5 011191 ITRUSTLANDS AT TW SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME"Sr.FIRST) / PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 1-' r to-01 7 90 <br /> NIGHTS: NAME 0",FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 146.rrq.1d _bco f, M) '334-07961 <br /> IL PROPERTY OWNER INFORMATIONS ADDRESS—(MUST BE COMPLETED) <br /> NAMEA C• wo0a <br /> CARE OF ADDRESS INFORMATION <br /> QA eo <br /> MMLANG or STREET ADDRESS ✓Box to wcos ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Lxy�/� C.}• ❑ CORPORATION ❑ LOCAL-AGENCY ❑ =AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Lackli C 96*P-4D -71)d <br /> 111. TANK OWNER INFORMATION S ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDFAW ✓Box to Nxticats ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 8CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHEM ONE(1)90 MgICATNIG ElNC A•M AOOMM SHOINA EE UM FDR SOTN LEGAL NOTIFICATION A#W KUMG: L 5a IL � NI <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 I=OMLY <br /> CoLw"# DICTION M "IlmY Ir FACILITY 10 S r a TANKS a SITE <br /> [Eyl I I I -I [:[- i I (01.0 S a� lFolo 0 3 <br /> yl <br /> LOCAL A M-C7/FACiLTTt/ID N APPROVED by NAr1E PHONE•MIM AREA COD[ <br /> e i7 <br /> PEIIWT PEPAW APPIMAL DATE PERM EXMMTION DATE <br /> LOCAV"CODE CENsIrS TRACT. COOS oUsomMil PLAN Fum DATE f`EO <br /> 9 as 3. 2 YES ❑ ND ❑ �' �s oo <br /> N CHI"f PEPAWT AMOUNT SURCHANN AMOINIT FEE CODE RECEWT N oY: <br /> THIS Fm aw m ACED sY AT LEA*4q Olt 11011E TANK~FORM 13'APFLN:A=Rs),1-kM THN IS A OM M OF SM WOIMIATION ONLY. <br /> FORM A(3.2-0) <br /> DATA PROCESSING COPY <br />