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STATE OF CALIFORNI}Nr WATER RESOURCES CONTRbawBOARD <br /> FORM NA': <br /> UNDERGROUND STORAGE TANK PROGRAM = " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACT /SITE " <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT E4<cHANGE OF INFORMATION 7_P LY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> /,( LA a a l �v 64v u' <br /> ADDRESSNEAREST CROSS STREET ✓Be aYdiule ElPABINEHSRIP ElSTATEAG <br /> 3 / El WIPGMTGN LlLOCAL-AGENCY ❑ FEDER/ AGDO <br /> D 6 5. A I p4d <br /> ❑ IWMA ❑ CWNWAGENCY <br /> CITY NAME STATE ZIPCODE SITE PHONE N.WITH AREA CODE <br /> CA 2aY f3iI 9 0 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P5gaSSOR ✓8ox i(INDIAN EPA ID M <br /> RESERVATION Or Not TANK's O <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHEfl TRUST LANDS ❑ ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME( FIRST) PHONE N WITH AREA DE/ DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> AE wE `7' -%l.76 - Y <br /> NIGHTS'. NAME(LAST,FAST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N / N o1 TANKS at SITE <br /> ailIBJ ( V <br /> CURRENT LOCAL AGENCY FACILITY IDS- APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION 40D CENSUS TRACT N SUPERV R-DISTRICT CO BUSINESS PLAN FILED DATE FILED <br /> G(/ J 2 YES [] NO � <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUIW FEE CODE RECEIPT N BY:, / a <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 0!)ET� <br /> M A(3-2-88) (\l <br />