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37 <br /> STATE OF CALIFORI °. <br /> WATER RESOURCES CONTISBOARD ` '°^« <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE C° FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> �9lIFOF_N1P <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PNTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E]6 TEMPORARY SITE CLOSURE gO <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME e CARE OFA ESS INFORMATION <br /> ADDRESS (L / NEAREST C OSSS REST ✓Bov to lno¢al¢ [' piNEASHIP ❑ SiATE-AGENCY N <br /> 24 D \..I�'l(��- C,/y ❑ CORPORATION OCALAGENCY ❑ FEOEAALAGEKY <br /> x r Y l a ❑ INDIVIDUAL COUNiYAGENCY (-0 <br /> CI NAME <br /> STATE ZIP CO E ITE PH NE a,WITH AREA CODE <br /> CA !) JW 2757 <br /> TYPE O BUSINESS'. ❑ 2 DISTRIBUTOR 1[7]:4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑3 FARM OTHER RESERVATION or #oI TANKS <br /> TRUST LANDS ❑ AT THIS SITE63 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGIENCY CONTACT PERSON(SECONDARY) <br /> Or NAME(LAST,FIRST) PHONE N WITH AREA CgODE DAYS'. NAME(LAST FIRST) PHO T N H AREA CODE <br /> -Z7 ] / r/` <br /> SAll <br /> NIGHTS: N E( FIRST( PHO Ea WITH AREA CODE NIGHTS: NAM (LAST.FIRST) PHONE WH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> N CARE ADDRESS INFORMATION <br /> 1 !^b <br /> II <br /> MAILING-orr ETA R SS ✓Box tointlicate 13 PARTNERSHIP ElSTATE-AGENCY <br /> Z ` a 11 CORPORATION ❑__66CAL-AGENCY ❑ FEDERALAGENCY❑ INDIVIDUAL (C COUNTY-AGENCY WITHAREACOOE <br /> CITU N9M STATE ZIP CODE PHONE <br /> S L(//AQ C 4�ZD Z 20 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME (�// ��j.���� CARE �DDRESS INFORMATION <br /> / L ff atr � <br /> MAILINGo, R)=ET ADDRESS Box to intlicate ❑ PARTNERSHIP LlSTATE-AGENCYJ(� ❑ CORPORATION ❑KCAL-AGENCY ElFEDERAL-AGENCY <br /> ❑ INDIVIDUAL COUNTYAGENCYCITY NAM /I^I STATE ZIP COD PH E a ITH AREA CODE <br /> 1 <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. II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# If of TANKS a1 SITE <br /> 0 lo oU' 3 <br /> ffRt <br /> Y F�ITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIONENSUS TRACCTbTA# SUPER ISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILE <br /> Z x0(Jvb� 11 YESEJ NO ERMIT AMOUNT SUR HARD AMOUNT FEE CODE RECEIPT# Y. P EC`1 <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 /> �' <br /> 0 DATA PROCESSING COPY <br />