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TATE OF CALIFORNIP WATER RESOURCES CONTROO ARD5`�k, '"F <br />� S u o <br /> FORMW: <br /> . <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> S7MARK <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> R <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ��FO FNP <br /> ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CD <br /> CO <br />'i 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 1-46 <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> r0 -fq Oyu S a -000rd1 -61/0 <br /> ADDRESS NEAREST CROSS STREET ✓ xtoindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �J /®� /�� CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CJ' r yt ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> CA `t'Sa D s1 (.RoJAT <br /> TYPE O BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or f TANK'a <br /> lyl AS STATION ❑3 FARM ❑5 OTHER TRUST LANDS ❑ 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 /> d 85 - '!na lir, l 1, C�-r ?A-ba <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE <br /> � x �0%0 f -55-, a& sane.. <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> (7, <br /> kirsch <br /> MAILINd or STREET ADDRES ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> /p� <br /> ^ ❑ RPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> er e-r ,4 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> rw" <br /> .301 <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATN <br /> e)ezc VV # ul-ia C�a /�✓� <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cw7 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> , ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> C4 1 q <br /> 5'130 (A0j ?A-ba <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. ❑ it. ❑ III. <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 /> FPERMITNUMBER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> = I I I I I I I I E6161 ) 171 & L516101013 <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 3 <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUSTRACTT## SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LEDYES ❑ NOPERMIT AMOUNT SURCHARGE AM bUNT FEE CODE RECEIPT# 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 /> FORM A(3-2-88) . <br /> DATA PROCESSING COPY <br />