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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMAT: <br /> UNDERGROUND STORAGE TANK PROGRAM = � o <br /> SITE /1 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 Y CLOSED SITE H9 <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S-3 Q' <br /> 4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILI /SITE NAME CARE OF A DRESS INFORMATION <br /> ADDRESS NEARE OSS STREET mlo irdiWle 0 PARTNERSHIP 0 STATE AGENCY <br /> CO11=1DN 0 LOCALAGENGY 0 FEDERAL AGENCY <br /> ElINDIVIDUAL 0 Won AGENCY <br /> CITU AME STATE ZIP DE/��� SITE <br /> RHO p,WITH AREA CODE <br /> CA S <br /> TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 1,PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ I GAS STATION 3 FARM 5 OTHER RESERVATION or X of TANK'e 0 <br /> ❑ TRUST LANDS ❑ AT TNIS SITED <br /> EMERGENCY CONTACT PERSON(PRIMARY) EME GENCY CONTACT PERSON(SECONDARY) <br /> D S'. NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS. (LAST,FIRST) P E N WITH AREA CODE <br /> ?moi - 6 Xd 4 <br /> NIGHTS. �A. E(LAST, RST) PHONE N WITH AREA CODE NIGHTS'. N E(LAST,FIRST) P E X WITH AREA CODE <br /> �Cj `TAA ?vjAd <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST Bk COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP Cl STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMV6 <br /> CARE OF DDRESS INFORMATION <br /> ING or STREET ADDRESSox to intlicale 0 PARTNERSHIP 0 STATEAGENCY <br /> EJ CORPORATION 0 LOCALAGENCY0 FEDERALAGENCY <br /> D 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP Ci00E PHONE p,WITH AREA CODE <br /> -7 4CL IV. LEGAL NOTIFICATION AND BILLING ADDRESS C `J1/ 9 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111. <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 If AGENCY# FACILITY 10# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE X WITH AREA CODE <br /> PER T NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCOM <br /> CATI NCODE CENSUSTRACTX SUPERVISOR-)11STRICT CODE BUSINESS PLAN FILED 'D EFI D <br /> Z_X VES NO <br /> ECK# I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1LOR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-SB) <br /> C_ <br /> 0 <br /> -$ 1 art DATA PROCESSING COPY .;.► <br />