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y <br /> 0 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> n COMPLETE THIS FORM FOR EACH FACILITY/SITE , <br /> MARK ONLY ❑ ',>WN PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED E <br /> ONE ITEM LLLCCC�NJJJ"`i INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 0 F,► <br /> Lq <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓CORPORATIO 0 PARTNLOCAL RISNOPADEN STATEAGENCY <br /> AGEN <br /> ❑ CORPORATION ❑ LOCAL ❑ {EOEMLAGENp <br /> [IINOMWAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP ODE SIT HONE N.WITH AREA CODE <br /> CA 3710 <br /> TYPE OF BUSINESS Z DISTRIBUT I P SSOR ✓Bax if INDIAN EPA ID p M of TANK'N <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSRESET LANDS ATION or ❑ _-/O?�// r AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: E(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> (0S IV7- yS <br /> NIGHTS: NAM (LAS .FIRST) <_PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME JD PJI f o` 6,o?eral 516r ceS CARE OF ADDRESS INFORMATION <br /> /�;25 <br /> MAILING or STpEET ADDRESS �� ✓Box to indicate ❑ El FEDERAL-AGENCY <br /> PARTNERSHIP STATE-AGENCY <br /> D CORPORATION 11LOCAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU NAME �((Y/ STATE ZIP CODE��/�- PHONE k.WITH AREA CODE <br /> PL <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CNECK 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 R AGENCY N FACILITY IDR If of TANKS at SITE <br /> 3i / ITFOTvl I I I I / <br /> CURRENT LOCAL AGENCY FACILITY ID Or APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBERLAMOUNT <br /> MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NOCNECK• SURCHARGE AMOUNT FEE CODE RECEIPT Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL":" <br /> \�/II FORM A(3-2-88) \/) <br /> -Ya- <br /> Z/`/-I \� DATA PROCESSING COPY ��� / <br />