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STATE OF CALIFORNIA WATER RESOURCES CONTROL 0ARD <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM <br /> TION and/or PERMIT APPLICATION <br /> SITE FACILITY/SITE, INFORMA <br /> C9lllOPi�P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 7 PERMANENTLY CLOSED SITE <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OFINFORMATION 00 <br /> MARK ONLY s TEMPORARY SITE CLOSURE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CA E OF ADDRESS INFORMATIONnom/ <br /> FACILI /SITE NAME_ j /- <br /> J•' <br /> L) NEAREST CROSS STREET ✓Bocm rcdirste ❑ VAWNBISNIP ❑ STArFAGENCY <br /> FEDERAL AGENCY <br /> ADDRESS <br /> - / _ INUIVDUALGN ❑ CCUNIY AGENCY ❑ <br /> �J •�, G7 LD-Z �G-e� STATE Zip CODE SITE PHONE a,WITH n c A J1,4 �E CODE <br /> �� <br /> CITU ME � ID # /U� <br /> T/(FUSIN ✓Box if INDIAN EPA IDa #oITANK'c / <br /> TYPE OF BUSINESS'. 2 DISTRIBUTOR 4 PROCESSOR RESERVATION or AT TNIS SITE .�!. <br /> I GASSTATIDN [:]3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) /C PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> PHONE b WITH AREA CODE <br /> /�i/- _c /1 x ,�J l 110 L�l— 9� PHONE 4 WITH AREA CODE <br /> '. ,FIRST) PHONE a WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) <br /> NIGHTSNAME(LAST <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST ADDRESS <br /> BE COMPLETED) <br /> CARE OF <br /> NAM � � <br /> fM � f YK-S ✓Box to indicale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> MAILING or STREET <br /> IADDRESS <br /> '1� /�y Q �p NDN DLL ❑ LOCAL <br /> AGENCY <br /> ❑ FEDERAL-AGENCY <br /> 3�� AIO• WGI7 U��I� ✓✓I�' STATE ZIP COLE PHONE p,WITH AREA CODE <br /> CITY NAME <br /> ml0.sml , �IoridCt_, <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)DCARE OF SS AnoN <br /> NAME�IlLIV-� IQL�C,J�. <br /> K ✓Box to lnrlicate [IPARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS Is CORPINDVORALON ❑ COUNTY-AGENCY AGENCY El LOCAL-AGENCY ❑ FEDERALAGENCY <br /> lla3� �rc�c4o ✓I"� �u /� / ]� STATE ZIP CODE PHONE# WITH AREA CODE <br /> CIAME <br /> 7ZOc C CF�VCIDJGL <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=9; <br /> HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> URE) <br /> LOCAL A <br /> C'YII#VIII FACILITY ID# #of TANKS at SITE <br /> COUNTY# JURISDICTIONAGEN <br /> 3 APPROVED BY NAME PHONE k WITN AREA CDOE <br /> CURRENT LOCAL AGENCY FACILITY 10 N <br /> RPERMIT EXPIRATION DATE <br /> PERMIT NUMBER PERMIT APPROVAL OATS <br /> LOCATION CODE CENSUS M SUPERVISOR-Dill CODE BUSINESSMEN FILED NO ❑ OATE FILED D <br /> 1' 2 SJ FEE CODE RECEIPT# 3BY: <br /> nl SURCHARGE AMOUNT P <br /> \\ <br /> CHECK k PERMIT AMOUNT C-� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST( R MORE TANK PERMIT FORM rBr APPLICATION(S), UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY 49 <br />