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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ye "0' <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM %a z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE H6 j <br /> ONE ITEM Cl2 INTERIM PERMIT El4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) All <br /> FACILITY/SITE NAME _ y CARE OF ADDRESS INFORMATION O <br /> 1k <br /> ADD SS r(� N REST CROSS STREET ✓ iM TIO ❑ LOCAL <br /> ❑ FSTATE EDERAGBILI" <br /> t CAAPOAATION ❑ LOCPIAGENp ❑ FEDERAL AGOKY I <br /> he. ia,Z4 /h ❑ INDIVIDUAL D COUNTYAGENCI <br /> CITY NAME • STATE P CODE SITE PHONE A,WITH AREA CODE <br /> CA <br /> 9�" S CaoR tf�G�G7ab <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box it INDIAN EPA ID x�/�'�,.� %of TANK's <br /> ❑ T GASSTATION ❑ 3 FARM F�JOTHER RESERVATIONRUSTLANDS o ❑ AT THIS SITE D <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(I-AST,FIRST) PHONE 0 WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP Cl 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 /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0,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: 1. ❑ 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 P JURISDICTION N AGENCY M FACILITY ID R K of TANKS at SITE <br /> a 10 10 1 a � a ootid <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE*WITH AREA CODE <br /> /V 1-1— <br /> PERMIT NUMBER PERMIT APPROVAL DATE PEflMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Cd(%hf n YES NO Ir <br /> 1 <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM Y: <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 /> FORMA(3-2-88) (� <br /> 'y DATA PROCESSING COPY - <br /> � I <br />