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C ^ <br /> STATE OF CALIFORNO WATER RESOURCES CONTRIPBOARD l <br /> SEPI � .lti <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE 7C/i <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> EA ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE YCLOSED SITE <br /> ITEM ❑p INTERIMPERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> / <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 10 <br /> FACI SITE AME AA CAgE OF DESS INFORMATION <br /> V <br /> AODRES � (( NE PES CROSS STREET 7 ✓ ailHcgle ❑ PARINERS4IP ❑ STATE-AGENCY <br /> Po <br /> �Dl LN ORALGN ❑ LWI1Ntt AGENCY PAl GENLY '�a <br /> CITU E u STATE Z CODE SITE PHONE 4.WITH AREA CODE v, <br /> /TJ _> CA SILI O ;c 73—U Or, <br /> TYPE OF BUSINESS: ❑p DISTROUTOR ❑�y4 PROCESSOR ✓Box if INDIAN EPA D a <br /> ❑ 1 GASSTATION E] 3 FARM BCJ 5 OTHER RESERVATION or ❑ #of TANK's O <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAY AME(LAST FIRST) P ONE a WITH AREA CODE <br /> n� nI t17�D D <br /> HITSe NAME(LAST, IRST)• PHONE t WITH AREA CODE NIGHTS: NAME(LAS RS� I• PHONE q WITH AREA CODE <br /> ; A• <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME , 0 CARE OF A DpEBB INFORMATION <br /> MA-7 0 elILING or STREET ADDRESS ✓ x to indicate 13 PARTNERSHIP ElSTATE-AGENCY,n. A. CORPORATION 11LOCAL-AGENCYEl FEDERAL-AGENCY <br /> ��'���s��VVVaa�.V T�'� ❑ INDIVIDUAL 13COUNTY-AGENCYCI ME P CODE PHON a,WITH AREA CODE <br /> AT <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME /�"✓ V An CAREOFA D T:INFORMATION <br /> MAILING or STREET ADD SS a�B�ix 10 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> 717Y NAME STA _ ZIP C07 PHONE WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS S/ S A <br /> CHECK ONE(1)BOX INDICATING WHION ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ it. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> r <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID a If of TANKS at SITE <br /> MIZIK=3 b0 O <br /> CURRENT LO AL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 811 <br /> PERMIT NUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRA/CT# UPER S -DISTRICT CODE BUSINESS PLAN FILEDpq jol •b0 YES NOCHECK# PERMIT AMOUNT URCHARGE AMOUNT FEE CODE RECEIPT k 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) go <br /> DATA PROCESSING COPY 0 5 <br />