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STATE OF CALIFORNIPr WATER RESOURCES CONTROL:80ARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM = � o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F-] 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 /> 10 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 6MEVk-� 5 c* <br /> ADDRESS <br /> NEAREST CROSS STREET ✓Gor.NindWe El LOCALAGDO❑ PAUNDISIIP ❑ STATE"AGENCY r\)�. A Poer ❑ INpFNMD N ❑ CGNMY-AGENCY ❑ RDEfiAL AGENCY <br /> IM <br /> CMRTr_R WAY <br /> CITY NAME STATE ZIP CODE SITE PH NE If.WITH AREA CODE <br /> ST6::+e70/J CA 1?520.5 ZO9 948 3t5 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID 4 - #of TANK's <br /> ESE <br /> GABSTATION ❑3 FARM E] 5 OTHER TRUSTY <br /> ATION LANDS or ❑ O AT THIS SITE <br /> Iv I ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> fbAJ J — 209 - 316Suphler, TED I 448-4-516 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGH S: NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> Zo9 52.- I OTT &P.ALGE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S +E LL L GOn� A <br /> MAILING or STREET ADDRESS ✓� qoxtoindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> p p W-CORPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY <br /> O II $ ROAD �j(J "[E IOo ❑ INDIVIDUAL ❑ COUNTY.AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Cowc,opwo ca• a 15) 4,741- 1414- <br /> Ill. <br /> /,- 141111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> L OIL GO <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> LIT CORPORATI137e) S O OQ INDIVIDUAL ON ❑ COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Nwp-D CA- 45'LD 415) 7(0-141 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ASOVE 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&SIGNATU DATE <br /> G L6 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCYIP FACILITY ID IT N of TANKS at SITE <br /> Eli] 0 10 1 i o = <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUNBER k3 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> a YES NO <br /> CHECK# PERMIT 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 INFORMATION ONLY. <br /> F RM A(3-2-88) <br /> DATA PROCESSING COPY <br />