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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> .. A <br /> FORMW: ' m <br /> UNDERGROUND STORAGE TANK PROGRAM �n <br /> SITE /} FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAACHH FFACILITY/SITE <br /> MARK ONLY El1 NEW PERMIT E]3 RENEWALPERMIT � CHANGE OF INFORMATION ❑7 LY CLOSED SITE IV <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT — 6 TEMPORARY SITE CLOSURE 6' <br /> !t <br /> C <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/'T')N[�ME. L3L)rl 'kjn n� t— CAREOF ADDRESS INFORMATION <br /> ADDRE I 4K./•r K K� TI NEAREST CROSS STREET ✓BW"bntliuk ❑ PARTNBSINP ❑ STATEAGENCY <br /> S / Q.Y) n �P0'TION ElLom.AGENLY ElFEDERAL-AGENCY <br /> 9JNDYIWAL ❑ CWM AGENCY <br /> CITY NAME A STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Lod I CA 95 �'�O 6SF- <br /> TYPE OFBUSINESS ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID n <br /> RESERVATION❑ ❑ TRUST LANDS or ❑ #of HIS SITE t GAS STATION 3 FARM OTHEfl pof TANK1TE <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 /> NIGHTS: NAME(LAST,RRST) PHONE If 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 /> 5 wrv0- <br /> MAILINGorSTREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME — N^QQ �/ CARE OF ADDRESS INFORMATION <br /> WI,ik <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 1 <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. orIL ❑ 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# JURISDICTION# AGENCY# /'� FACILITY ID# #of TANKS at SITE/ <br /> I F I � D V ,� l_J <br /> CURRENT LOCAL AG CY FACILITY I It - APPROVED BY HAVE PHONE#WITH AREA CODE <br /> u -dl& ?Is& em <br /> PERMIT NUMBER PERMIT APPROVAL DATE OERMIT EXPIRATION DATE <br /> LOCATION CODE V 1 CENSUS TRACT k UPERVISOR-DISTRICT CODE BUSINESSPLAN FILED DATE FILED <br /> YES NO �tL <br /> CH CKM <br /> ELPERMI AMOUNI—_ SURCHARGE AMOUNT FEE CODE RECEIPfM BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 0)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORv(3-2-58) <br /> O�� ..r DATA PROCESSING COPY <br />