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STATE OF CALIFORNP WATER RESOURCES CONTROL BOARD SPfU�N;T" <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM W`� Aim <br /> �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ov COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 10 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> oalgl&z Owe, 1`10 <br /> ADDRESS NEAREST CROSS STREETindicate El PARTNERSHIP ClSTATE-AGENCY <br /> OAPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> lA4Q3e f INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA CODE <br /> FJ cA W,3 -Owp <br /> TYPE O USINESS: ❑2 DISTRIBUTOR F—]4 PROCESSOR ✓Box if INDIAN EPA ID # If of TANK's <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 It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> sc>r.1 grLq 030-mf �-- <br /> NIGHTS: NAME(LAST,FIRS 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 /> Mmal L_ Of L- <br /> MAILING or STREETRESS �✓ x to indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> LTJ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY N ME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> N or <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> migalL <br /> MAILING or STREET ADDRESS ,�✓ tto indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ?'CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STA® ZIP CODE PHONE#,WITH AREA CODE <br /> L <br /> IV. LEGAL NOT (CATION AND BILLING ADDRESS 7 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 111.❑ <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> Ea O1 ® OD <br /> ,yj <br /> CU RENT LOCAL AGEN Y FACILITY ID# APP VED BY NAI PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERM( EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DI RICT CODE BUSINESS PLAN FILED DAT ILED <br /> 23 YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT EE FCODE 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 /> FORMA(3-2-88) DATA PROCESSING COPY <br />