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STATE OF CALIFORNIJ�r WATER RESOURCES CONTROL BOARD <br /> FORMAI: <br /> SITE UNDERGROUND STORAGE TANK PROGRAM <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLI Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE CATION <br /> MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> ❑ <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE <br /> 2 INTL,a <br /> ❑ ERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) coA <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> NEAREST CROSS STREET t, PMTNEMHW STATE.AGENLY <br /> T ✓pm m El�OSNPoAAnON ❑ LOCALMEKG ❑ FEOxAL-AGDO <br /> CITY NAME 0uu 0 INONEIMI ❑ COUNTr AGRICY <br /> STATE ZIP CODE ITE PHONE p.WITH AREA CODE <br /> cA 5'-2 qZ <br /> TYPE OF BUSINESS: Lj2 DISTRIBUTOR ❑4 PRpCESSpR ✓gox if INDIAN EPA ID N <br /> tlGAS N 3 FAflM 5 OTHER RESERVATION or �/ M of TANK's❑ TRUST LANDS ❑ /{7 d t� A7 THIS SITE <br /> Y CONTACT PERSON(PRIMARY) EMERGENCY CQNTACT PERSON(SECONDARY) <br /> ST,FIRST) PHONE N WITH AREA CODE DAYS- NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> tm /i� � ' V " velh.� (3j°-y7S/ <br /> LAST,R ST) PHONE N WITH AREA CODE NIGHTS: NAME(LAS .FIRST) PHONE N WITH ARE/A�ODE <br /> :zit <br /> II. PROPERTY OW ER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> f1R/E �� JS/4ra< <br /> MAILING or STREET ADDRESS ✓Sax tointlicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> /tom,.t ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME DIVIDUAL ❑ COUNTYAGENCY <br /> STATE ZIP CODE PHONE Jr.WITH AREA CODE <br /> z>s/z <br /> F III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME�r.e= c�tiL"l�a�Pfa <br /> CARE OF ADDRESS INFORMATION <br /> MAILINGor STREET ADDRESS ✓Sox tointlicate 13 PARTNERSHIP 11STATE-AGENCYLJ ISA A/�. Q� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE N,WITH AREA CODE <br /> szyz 7c 25`S�Z <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: 1. 19 II. ❑ 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 M JURISDICTION R AGENQV-R FA ILITY IDR N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N "APPNOVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DAVOE - -' PERMIT EXPIRATION GATE <br /> LOCATION CODE CENSUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES E] NO ❑ <br /> CHECK 0 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BEACCOMPANIED 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 />