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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 1 <br /> UNDERGROUND STORAGE TANK PROGRAM = " o <br /> SITE INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION 7 PE YCLOSEOSITE I r* <br /> ONE ITEM ❑ 2INTERIMPERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / Gr <br /> LTi <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) _s N <br /> FACILI /SITE NAME CARE OF DDRESS INFORMATION <br /> �rc 44c <br /> ADDRESS vj ` -�/ > - �// NEAREST CROSS STREET ✓Bo' mao ❑ PAHTNEHGHIP ❑ STATE AGENCY <br /> [ 5 , J� / LJ LBAPOAATION ❑ IOGLAGENCY ❑ FEDERAL AGENCY <br /> J ( B'INONIOUAL ❑ COUNttAGENCY <br /> CITU NAME STATE ZIP CODESI <br /> GATE PHO E p,WITH AREA CODE <br /> TYPE OF BUSINESS ❑ p RIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> ❑ 1 GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ �/ AT THIS SITE d D <br /> ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAM ST,FIRST) P #WITH AREA CODE DAYS- NAME(LAST.FIRST) PHON #WITH AREA CODE <br /> SHO s 9a <br /> NIGHTS'. NAME(LAST.POST) P Y!WITH AREA CODE NIGHTS! AME(LAST,FIRST) PHg p-WITH AREA CODE <br /> J 7� /7� .'/+� <br /> 11. PROPERTY OWNER INFORMATION it, ADDRESS - (MUST BE COMPLETED) <br /> NAME 2A <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.Io indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK_OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME Q / CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS N/✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ 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: I. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID At #of TANKS BI SITE <br /> � o © 0 <br /> CURREIN/T/LOCA��%FACILITY ID# APyf�OV�q BY N PHONE#WITH AREA CODE <br /> PERMIT NUMBER 3 PERMIT APPROVAL DATE /`��pL PEAMITIERPIRATION DATE <br /> LO TION CODE CENSUS TRACT 0 SUPERVISOR-DIST ICT CODE BUSINESSPLAN FILED NO T.FI ED <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 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> la.. DATA PROCESSING COPY ti/ <br />