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I <br /> STATE OF CALIFORNI)t WATER RESOURCES CONTRO'riOARD <br /> W. <br /> FORM I UNDERGROUND STORAGE TANK PROGRAM � o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } � <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'6i•._a=`" <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE z <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) ) <br /> FAC ITV/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEA EST CROSS STREET ✓ to iP4iwte D PARTNERSHIP D STATE AGENCY <br /> D DrvPo6RnNNe O LOCAL <br /> ❑ �nEAA1 ACE,+a r- <br /> CIN NA STATE ZIP CODE SITE PHO E k,WITH AREA CODE -916 <br /> "i CA Cl <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR '/Box if INDIAN EPA ID # <br /> ❑ I GAS STATION L] 3 FARM OTHER TRUSRESETVLAND$ATION o ❑ AT THIS SITE 6 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS )AVE(LAST,FIRST -PHONE N WITH AREA CODE DAYS: NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> Y,47 cb G - 205)'/tuna Sf-'Avi <br /> NIGHTS. NAME(LAtT,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(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 ✓Bos to in0icate D PARTNERSHIP D STATEAGENCY <br /> D CORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF AD HESS INFORMATION <br /> SL ,Ax 0S G <br /> MAILING or STREET ADDRESS Or ✓BL' no cafe ❑ PARTNERSHIP ❑ STATEAGENCY <br /> _ c LL}�ORPORATION ❑ LOCAL-AGENCY D FEDERALAGENCY_5760S /� / —v I D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> C 22LL4 1 N/i <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. ❑ it. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,)S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID Al a of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# AZ"D BY NAME PHONE#WITH AREA CODE <br /> ,5c-ASE 10 T <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> E CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p BY. <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 /> FORM A(3-2-88) <br /> DATA PROCESSING COPY �� <br />