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STATE OF CALIFORNIP WATER RESOURCES CONTROSOARDa 'FX <br /> Ire. ;rA <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE <br /> r ®, O <br /> FACILITY/SITE, / APPLICATION � <br /> COMPLETE THIS FORM F CIL{ /S{T �gL110 V <br /> MARK ONLY ❑ 1 NEW PERMIT ® 3 RENEWAL PERMIT 5 CIAGE OF INFO NATION ❑7 PERMANENTLYLOSED SITE <br /> ONE ITE ®2 INTERIM PERMIT ®4 AMENDED PERMIT TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> c <br /> ADDRESS NEAREST CROSS STREET ✓BN IO xdR0 ❑ PARTNF&IP ❑ STATE AGENCY <br /> 3300 u)a /0 0 � ® INDIVIDUAL 0 COUNTY-AGENCY <br /> ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIPJ;OD�E�®� BITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑2 DISTRI UTOR ® 4 PROCESSOR ✓Box it INDIAN EPA ID # 66//cc�/ III,/7o/ff/OTAN��•7? <br /> RESERVATION or <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 /> w 01) T X9 ..__5 -offal t2ldW 7r .2l0'ow <br /> NIGHTS: NAME(LASI'FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Van Vramizn l? <br /> 11. PROPERTY OWNER INFORMATION -(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> GU ✓& P k-i, S e% <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> y, / ► ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> l% W INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CE PHONE#,WITH AREA CODE <br /> ff Yd <br /> 111. TANK OWNER INFORMATION - ( ) <br /> NAME CARE OF ADDRESS INFORMATION <br /> N: Ju11'e- CQldw <br /> MAILING or STREET ADDRESS ✓Elex to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> / CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE P NE#,WITH AREA CODE <br /> n � � o � - oa (f 1 <br /> . LEGAL NOTIFICATIONILLI <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ IL ® III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> rP`IOANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE L <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS at SITE___l E r------T_ <br /> " <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 13 a4 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS N FILED DATE FILED <br /> 0 1 8� 3�3 <br /> YES N® - 7-�0 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNTFEE CODE RECEIPT# BY: <br /> YMS FAVMUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT ICATIO (S),UNLESS THIS ISA CHME OF SITE INFORMATION ONLY. <br /> FO 2-88) <br />