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STATE OF CALIFORiSA WATER RESOURCES COAL BOARD <br /> 22 �. <br /> FORMAN: <br /> UNDERGROUND STORAGE TANK PROGRAM 7 _ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATI ' <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEftEAMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE )- <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> C <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILHY/SITE NAME CARE OF ADDRESS INFORMATION C <br /> oormati MfG so Ar, t <br /> ADDRESS n NEAREST CROSS ST ECT ✓8nnmiule D PARTN V D STATEUVIIANUTION AGEHLY <br /> IP�50 E O-I� S- 6— °a NIxvD.m O OJIM AGENU LOMAGDO ❑ fFfIEw1 NGUILY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> S oc �m-j CA 5330- ?z O'?-M-0/23 <br /> TYPE OF BUSINESS: ❑2 DISTPJBUTOR - A PROCESSOR ✓Box II INDIAN EPA ID x <br /> ❑ 1 GAS STATION ❑ BI 3 FA ❑6 OTNFA 7q ST)ANDS oI ❑ Sol <br /> AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME ILAST,FIRST) PHONE N WITH AREA CODE <br /> SorPAseN 207-?63-0/z 3 <br /> NIGHTS: NAME(LAST.FI I PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> rb«< ��-8z3-3off <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> M06rYMtj M T o- Co Lc? 'o 100" -a N <br /> MAILING or STREET ADDRESS ✓ ox Io malt le D PARTNERSHIP ❑ STATE AGENCY <br /> Q X CORPORATION D LOCAL AGENCY D FEDERALAGENCY <br /> INDIVIDUAL D COUNTY AGENCY <br /> CIN AME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> ,��40f 06,fi aA Or-wl <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMEe 4s CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to innicaln ❑ PARTNERSHIP D STATEAGENCY <br /> ❑ CORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D 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. ❑ IL III.❑ <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(POINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION B AGENCY E FACILITY ID R e of TANKS SI SITE <br /> ® I I I I I A 7 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER <br /> 4PERMITAPPRIVAL DATE PERMIT E%PIRATION DATELOCATION COOS CENSUS TRACT NPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE FILED <br /> 3�� YES NO 16 <br /> CHECK) PERYIT AMOUNTRCHARGE AMOUNT FEE CODE RECEIPT) BY:J <br /> [. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM rB'APPLICATION(S), UNLESS THIS IS A CHANGE OF S1TE INFORMATION ONLY. <br /> FORM A(3-2-BB) <br /> DATA PROCESSING COPY 0 <br />