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STATE OF CALIFORNm WATER RESOURCES CONTRC'CBOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM u �o <br /> SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> Til • COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /501 <br /> y <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 10 <br /> FACILITY/SITENA E CARE DRESS INFORMATION <br /> aces lSnp <br /> qj <br /> ADDRESS / NEAgEfST�CRO/Ss,S�TREET ✓Bw WinOicale ❑IAbTNEP3HIP ❑ SipiE-AGENCY N <br /> v �`^V" ❑ INDIVIDUAL <br /> D PORATTION ❑0 LO k-GNMc ❑ FmER4 ACRILY �Nyy0 <br /> CITY NAME STATE ZIP CODE SITE P NE#,WITH AREA CODE 00 <br /> TYPE OF BUSINESS CA S"Z 'L 0 <br /> 2 DISTRIS <br /> ❑ DISTRIBUTOR 4 P ESSOfl ✓Bpx if INDIAN <br /> EPA ID N <br /> ❑ RESERVATION or If of TANK'S <br /> ❑ I GAS STATION ❑3 FARM OTHER TRUST LANDS ❑ pT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(IAST,FIRST) PHONE N WITH AREA CODE DAYS: (LAST,FIRST) E#WITH AREA CODE <br /> 2oxi -1/07 5A <br /> 0 <br /> N HTS: NAME(LAST, RST) PHONE N WITH AREA CODE NIG NAME(LAST,FIRST) PH E p WITH AREA CODE <br /> .514 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) J <br /> NAME [CAA�REEF A pESS INFORMATION <br /> M LING or STREET ADDRESS rY�7�1• ✓Box to Indicate ❑��VPAARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION G'LOCALAGENCY ❑ FEDERAL-AGENCY <br /> 11 INDIVIDUAL 11 COUNTY-AGENCY <br /> CITY `E l •v STALE— ZIP CODE PHONE#. I AREA CODE <br /> Op',A, 4<7 m -a r o <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME A 0006wo 4 CARE F DRESSINFORMATION <br /> MAILING or STREET ADDRESS ✓ ox to indicate ❑ R RTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Lyf-COAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY N9 E STATE ZIP C DE PHONE N, ITH AREA CODE <br /> ]`{ /J1 CAS A <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDI IUB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 111. ❑ j <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# #of TANKS at SITE <br /> b 16 10 101 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M8U►ERVISO -DISTRICT CODE BUSINESS PLAN FILED D T FILE <br /> x YES NO ElZ g' fG <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 /> FORMA(3-2-88) ^ <br /> `i DATA PROCESSING COPY (J\l <br />