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TATE OF CALIFORNIP WATER RESOURCES CONTRAOARD <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM _ <br /> SATE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C�lF ORs�P <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER CLOSED SITE Fy <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 I Ir CARE OF ADDRESS INFORMATION <br /> 5co �4Y 5 BAIT i 7aIi . <br /> ADDRESS // J,{_ T NEAREST CROSS STREET ✓Barlolndlcale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Z A4 e �/k'e ❑ INDIVIDUAL <br /> ❑ COUNTY-AGENCY <br /> OU TYAGENCY ❑ FEDERALAGENCY <br /> CITY NAME r STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CA !W -74 <br /> TYPE OF INESS F-] 2 DISTRIBUTOR 4 PROCESSOR ✓Bax if IND AN EPA ID # #of TANK's <br /> RESETRUST LANDS ATION or <br /> 1 GAS STATION E] 3 FARM � 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -��� �e� <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS l6w<lndicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> &4h-1-17 <br /> /L/7A , 1y / CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> `/l// (y�{J�'�i ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> TT— AREA <br /> CITY NAME STAT ZIP fDj�6 PHONE#,WITj3_s <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) ��! fJ <br /> NAME ,+ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. pr IL F-1 III. g <br /> THIS FORM HAS BEEN COMPLETED TINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGF, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> j0joj /j_4tKZ <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATM QODf CEkSU5 1 CT MO SUPERYISOIST CO E BUSINESS PLAN FILED ❑ DATE FILED <br /> +�7/ YES NO s� - 0 <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 `Br APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FORMA(3-2-88) <br /> (1t 1 DATA PROCESSING COPY <br />