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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PROGRAM 7 " �o Z <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m+ I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENT CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 00 <br /> N <br /> I.FACILtTY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) F-+ <br /> FACIU7Y/SITE NAME �+ CARE OF ADDRESS INFORMATION <br /> S J G'r l ✓PiYV /1 SOC <br /> NEAREST CROSS STREET —✓ a11Q,a, D PARTNERSHIP D STATE AGE10 <br /> ADDRESS <br /> n <br /> SMI <br /> 11 LOCALO FFmw'AGM <br /> J ' ❑ NOMI ❑ OoLum-AWNCY <br /> CITY NAME ^ STATE ZIP CODE TE PHONE N.WITH AREA CODE <br /> J CA C15A6 9 Q- <br /> TYPE OF BUSINESS: ❑3 DISTRIBUTOR ❑Q4 CESSOR V`Box if INDIAN EPA ID N #of TANKb <br /> RESERVATION or El THIS SITE <br /> ❑ 1 GASSTATION ❑ 3 FARM OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE 'DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Me i if <br /> NIGHTS: NAME(LAST,FIRST) PH NEN WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> v <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STRE DRESS /� ✓Box lO iMicele D PARTNERSHIP D STATE-AGENCY <br /> S ^�;M , ❑DERIPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> J r'V V � IINDIVIDUAI ❑ COUNTY-AGENCY <br /> CITYNAME STATE ZIP CODE PHONE#, ITH AREA CODE <br /> a�M FiSA4,t d 03 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> '301)"s 04 S Owmer <br /> MAILING or STREET AESS v 4 ✓Boa to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ II. 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 R JURISDICTION M AGENCY N FACILITY ID N N of TANKS at SITE <br /> [Kil IDIC)l I 1 o 1 a (01 1010101 / <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> is 7!A G <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CE'2BTRACTN- SUPERVIBORQTRICT CODE BUSINESS PLANF❑ILED NO ❑ ,ATE �ED �� <br /> CHECK# PERMIT AAMOUNNT/y' SURCHARGE AMOUNT FEE CODE RECEIPT JII 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 /> \` f ECRM A(3-2-BBI <br /> V %no,, DATA PROCESSING COPY L,/ <br />