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STATE OF CALIFORNIA WATER RESOURCES CONTROLlr0ARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to <br /> Z COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 'S. -4 <br /> W <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 0 <br /> FACILITY/SI7EN E CARE OF ADDRESS INFORMATION <br /> n �e l erti- mud-a ga g es <br /> ADDRESS Jr NEAREST GROSS <br /> S�T(RE{{T ✓am N adow F1PARTNERSMP El STATE AGENCY <br /> LLAGENSY OI OVq U4 ❑ INNDRI11 WAIGN ❑ ClJI1NiY AGENCY ❑ EGEML @GBILY <br /> CITY NAME STATE ZIPCODE SITE PHONE N,WITH AREA CODE <br /> l.Ad� CA A-(U CITO <br /> 3�I I t m9 <br /> TYPE OF BUSINESS: 3 DISTRIBUTOR F-11 PROCESSOR ✓RESBox if INDIAN EPA ID N <br /> ❑ 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUSTLANDS ION or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE n WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br />!) NAME ` I n /N CARE OF DR ESS INFORMATION <br /> MAILING or STREET ADDRESS f�JCn,f' ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> r ❑ ATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> n I INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STAT I ZIP CODE Q "40PH'E0 ITH�A�j�E <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)5 <br /> NAME CARE OF ADDRESS INFORMATION <br /> SOL <br /> �9 Cs 02� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. C, <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 B AGENCY N FACILITY ID N a of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N gR� T>=SZ� APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT aSUPERVIS'O(R-DISTRICT CODE BUSINESS PLAN FILED DAT FILED ,, l <br /> �t ( 9 YES ❑ NO <br /> CHECK N PERMEE AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST[1)OR MORE TANK PERMIT FORM `B'APPUCATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-811) - <br /> DATA PROCESSING COPY ' <br />