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r 0 fOF• T <br /> STATE OF CALIFORN9 WATER RESOURCES CONTROL BOARD s� 'EuaiK,'•.NF, <br /> WP:• ';SA <br /> FORMW: <br /> : _. <br /> UNDERGROUND STORAGE TANK PROGRAM m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C"LIFOR N%P <br /> MARK ONLY F—] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT UZ5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE97 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP 0 WTE-AGENCY <br /> A2/� ❑ CORPORATION ❑ LOCAL-AGENCY FEDERAL-AGENCY <br /> oyy�x /'/� v/v kl l"Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 175R06—3Lzr)q- ,?-" <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ PROCESSOR ✓Box if INDIAN EPA ID# <br /> RESERVATION or #of TANK's <br /> ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> tiG4-- <br /> o9- i/ ©e?—/M-3WO <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(,LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCYCaNA2isO/i i ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY AAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 4,v 0,6/s D yO6 <br /> III. TANK OWNER INFOR ATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 11 l4111,1 P N8 Cf5777 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY J9 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. ❑ II. ❑ ill-kr <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 /> F <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> / — <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 r!� YES ❑ NO ❑ �'PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIEDBIf AT LEAST OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOR A(3-2-88) <br /> (� DATA PROCESSING COPY S <br /> t <br />