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7say-368 <br /> PX <br /> STATE OF CA�-.F.+ORN1P WATER RESOURCES CONTROL BOARD <br /> "tV XFN�•,P' <br /> FOR �9m <br /> k �JNDERGROUND STORAGE TANK PROGRAM W <br /> Sl «ta LITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> MAY 2 COMPLETE THISFORM FOR EACH F CILITY/SITE <br /> •q IIFORN�P <br /> ONI�EM'I / RRMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SED-SITE <br /> s <br /> 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ G TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 5MLL A S,4,W <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY was <br /> �/^^'( <br /> Cl CORPORATION 11 LOCAL-AGENCY ElFEDERAL-AGENCYo?3,;7-f� 0p_-r#• t Q ADAMS INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE If,WITH AREA CODE <br /> S-r Tv CA 9sao� ao9-9y3- /3// <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> 1 GAS STATION 3 FARM 5 OTHER RESERVATION or AT THIS SITE 3 <br /> ❑ ❑ TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> L uTz j 120 A&R-7- ��=/-9S/3-/ / L,-I-SrTEe :61,4 -9 S/.3-/3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE, NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> =� L u rg-7- o9- 76-/ I Av L.4 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 159 E L C O�4 SS A,07 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> ❑ <br /> a� CITY N STATE❑ INDIVIDUAL ZIP CODCOUNTY-AGENCY <br /> #,WITH AREA CODE <br /> olvcoep 9yS 9 yes-6�6 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTAT ZIP CODE PHONE#,WITH AREA CODE <br /> �aNca <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. ER] 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 NA (P INTED,B SIGNATURE) _ DATE <br /> LOCAL AGENCY USE ONLY <br /> FPERMITNUMBER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> LO a <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 YES ❑ NOPERMIT AMOUNT SURCHARGE AMOUNT 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 INFORMAT16. <br /> 1 FORM A(3-2-88) R (^ <br /> DATA&PROCESSING COPY "'}/�.J <br />