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PSTATE OF CALIFORNI WATER RESOURCES CONTROL BOARD <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM Y`� �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 7. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C9 LIFORN P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE OZ Q? <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) . <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ESC © 3, <br /> 16 C <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> L►L/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE mz2z <br /> SITE PHONE#,WITH AREA CODE <br /> -m� CA <br /> TYPE OF BUSINESS: F__] 2 DISTRIBUTOR ❑4 PROCESSOR */Box if INDIAN EPA ID# <br /> RESERVATION or #of TANK's <br /> ❑ T 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 /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I1. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME C E OF ADDRESS INFORMATION <br /> -S O A) Unt"704v� Its cam" /t�7z <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 11L� 71 <br /> El CORPORATION 1-1LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ']�w/ DA���4 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> Frc-705 I -�JD92_ <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> � US 6- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ,ems ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> S ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME r STATE ZIP CODE PHONE#,WITH AREA CODE <br /> I t C u.5'em -rx -:7-7n,72 <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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> F <br /> JURISDICTION# AGENCY# FACIILITY ID# #of TANKS at SITE <br /> 2E I- I I I E[ I I LL I / o <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> nt PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTjRICT CODE BUSINESS PLAN FILED DATE FILED19 23, 32/ YES ❑ NO ❑ 1 � pC) <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: O <br /> 1 <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 0 <br />