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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �• ' <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'i�ron+,r EC <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ®7 PERMANENTLY CLOSED SITE IV <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 CARE OF ADDRESS INFORMATION <br /> Don & Dorothy Kienitz <br /> ADDRESS NEAREST CROSS STREET ✓8mbii6ral¢ 0 PmTNmHP 0 SIATE.Aom <br /> 5575 E . Jones McHenr El caPORATDR 0 i0A D `� AGDO <br /> NiI0 clN1Y4mcY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Escalon CA 95320 None <br /> TYPE OF BUSINESS: ❑2 DISIAIBUTOR ❑1 PHOOESSQ,R ✓Box K INDIAN EPA ID It <br /> R <br /> RESERVATION or - of TANICp <br /> ❑ IGAS STATION �3FARM ❑ SOTHER ❑ <br /> TRUST LANDS CAC000612832 AT THIS SITE 1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME T AST,FIRST) PHONE#WITH AREA CODE <br /> ' ' z Dorothy 209-785-3960 <br /> NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> Kienitz Don 209-785-3960 <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Don & DorothV Kienitz <br /> MAILING in STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 4 CORPORATION 11LOCAL-AGENCY0 FEDERAL-AGENCY <br /> PO Box 464 L] INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> Copperopolis CA 1 95228 209-785-3960 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Don & Dorothy Kienitz <br /> MAILING wSTREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 FEDERAL-AGENCY <br /> PD Box 464 ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Copperopolis CA 1 95228 209-785-3960 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE AMISS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ® 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 /> Don Kienitz 7/10/91 <br /> LOCAL AGENCY USE ONLY 1-0 <br /> COUNTY S JURISDICTION It AGENCY# FACILITY ID M #of TANKS at SITE <br /> 3 I I C(ITEE] <br /> CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES [] NO 0 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> C6 <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 "f <br />