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STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD <br /> FORM 'AI: _ >- <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE G. FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' <br /> COMPLETE THIS FORM FOR EACH fA TY/SITE - 1O <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7,/,t6LOSED SITE rV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 07 <br /> fJT <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME w <br /> L /�h4 Vkk CARE OF ADDRESS INFORMATION77 <br /> ADDRESS V IV/ NEAREST CROSS <br /> /STREE� !RIY6068 ❑ P1AiNEpSWP ❑ SiPIFAGENCV <br /> CIN NAME0POUNT� 13❑ CEGALAGFNLY ❑ FEDERAL AGENCY <br /> IND.ISTATE ZISITE PHONE Y,WITH AREA CODE <br /> ttPE OF BUSINESS: I✓/vA4,1`� CA <br /> F-12 DISTR18UTOR ❑ q PROCESSOR ✓Box d IND N EPA ID a <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUSTVLAND ATIO or ❑ AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE Y WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to)Rule D PARTNERSHIP D STATE-AGENCY <br /> ❑-CORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONEa,WITHAREACODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Y,WITH AREA CODE <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 /> COUNTY M JURISDICTION R AGENCYAF FACILITY ID Al N of TANKS at SITE <br /> O lo Z, b 1 10 10 6) 171 <br /> CURRENT LOCAL AGENCY FACILITY ID YAPPROVED BY NAME PHONE N WITH AREA COVE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> ODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE. / <br /> YES [] NO ❑ <br /> !\��\ PEp 1 AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y BY: <br /> \ 6-11,1- <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 ON <br /> W1I FORM A(32-88) <br /> YYh, DATA PROCESSING COPY ...i <br />