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STATE OF CALIFORNIA,., WATER RESOURCES CONTROL�JARD <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F"M' <br /> ONE ITEM ❑ Z INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) ~ <br /> FACILITY/SITE NA K,/ CARE OF ADDRESS INFORMATION <br /> Tl P P�� � "U Yl�1L <br /> ADDRESS NEAREST CROSS STREET ��✓�B i3ub ❑ PAR 4015HP ❑ SIATEAGENY <br /> L YTDDWDNTIDN ❑ LDCALAWO ❑ RDERY,IGBILY <br /> 05 D5 t(✓'Z [ z Yyk_� ❑ N WRk ❑ CDUBYAGENCY <br /> CITY NAME - I 1 STATE ZIP C E SITE PHONE N,WITH AREA CODE <br /> }}L— CA SZQC� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑N PRDCESSOR ✓BoN if INDIAN EPA ID N Rol TANK# <br /> ESE❑ 1 GAS STATION ❑ 3 FARM OTHER TRATION <br /> UST LANDS DI ❑ <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA ODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> U 1�(` Y J <br /> MAILING or STREETD RESS L✓�gp Inllcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> `� 0 LOCAL-AGENCY <br /> �Q(�� b(,�)✓n 11INDIV DUAI-CORPORATION 11COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STAT ZIP OS14 \1 N <br /> DE PHONE ,WITH AREA CODE <br /> L(�ri� oc_ K� L13 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME Sa ,~L-Q CLD CARE OF ADDRESS INFORMATION <br /> � <br /> MAILING or STREET ADDRESS -/B..to Inftale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE " ZIP ODE PHONE N,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. ❑ 11. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY R FACILITY ID R R of TANKS BI SITE <br /> E51 a= 0 1 0 I U <br /> CURRENT LOCAL A NCYFACILrpf4D# APPROVED BY NAME PHONE N WITH AREA CODE <br /> FTE <br /> PERMIT NUMBER PERMIT APPR VAL DATE PERMIT EXPIRATION DATE <br /> LOCATION DOE CENSUS TRACT# SUPERVISOR-D STRICT CODE BUSINESS PIAN FILED DA FILED <br /> o YES ❑ NO ❑ a i <br /> CHECK# PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT BT: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST'MOR MORE TANK PERMIT FORM 'B'APPLICATION($),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> _ FORM A(3-2-SB) <br /> \TA PROCESSING COPY <br />