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STATE OF CALIFOF*`IIA WATER RESOURCES COP`ROL BOARD <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITECi FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C� COMPLETE THIS FORM FOR EACH FACILITY/SITE IsppN�� <br /> n <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMIAN TLY LO D SITE 1 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> r I.FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> R FAG TV/SI NAME /1� � CARE OF�RESS INFORMATION <br /> .... <br /> ADDRESS - /� NFA ST GROSS STREET ✓Boxbkiule ❑ PARTNEN9gP ❑ STATE-AGENCt <br /> . X //`Jxf�/'- L ❑ WRPOMTION ❑ LOCAL-AGENCY <br /> V ❑ NDIVDUAL ❑ COUNTY-AGO& <br /> CITY NAME STATE ZIP ODE LSITE PHO E WITH AREA CODE <br /> cA Z` 2 <br /> Box H INDIAN EPA ID N /1j <br /> TYPE OF USINESS: ❑y DISTPoBUTOR ❑ 4 PROCESSOR RESERVATION Ix Q AT THIS SITE (/ <br /> U '�STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ /U / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> RP NE N WITH AREA CODE <br /> DAYS: E(LAST,FIRST PHONE N WITH AREA CODE YS�N E(LAST.FIRST) <br /> YIA <br /> 7~A NE N WITH AREA CODE <br /> NIGHTS: NAME Is'!FIRST) <br /> PHO E N WITH AREA CODE NIGHTS: ME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION &ADDRESS —(MUST BE COMPLETED) <br />`. NAME CARE OF ADDRESS INFORMATION <br /> S/A <br /> MAILI G or STREET ADDRESS -w/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> y CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CAPE OF ADDRESS INFORMATION <br /> MAKING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ..r ❑ CORPORATION ❑ 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 ADDRESS11 <br /> CHECK ONE(f)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. it. ❑ 111•❑ <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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br />• COUNTY#f JURISDICTION M AGENCY N FACILITY ID N M of TANKS at SITE <br /> 1- 3111 �� oW71 o o o <br /> C PENT LOCAL AGENCY FACILITY 10 N APP OVED BY NAM PHONE N WITH AREA CODE <br /> R <br /> SL A 3 L Z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXIIIIRATION DATE <br /> LOC ON CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED NO ATE FILED Z, (j�w <br /> FEE C <br /> i CHECK N PERMIT AMOUNT SURCHARGE AMOUNT ODE RECEIPT N 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 /> i' <br /> FORM A(3-2-88) <br /> �..a DATA PROCESSING COPY L <br />