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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or ERMIT APPLICATION <br /> d 10 <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE `�,H•. <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE rV <br /> C: <br /> ONE ITEM 2INTERIM PERMIT 4AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Qq <br /> W <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Batawule 0 PARTNEASHIP 0 KATE AGENCY <br /> _ Cl WRP04TION ❑ LOCALAGENCY ❑ FEDEMLAGENCY <br /> 0 INDNIDML 0 WUNlY AGENCY <br /> CITU NAME STATCA ZIP CODE SITE PHONE#.WITH A�CODE <br /> q ` 3 <br /> TYPE OF 1379SS: 2 DISTRIBUTOR Ej 4 PRDCESSOR ✓Box if INDIAN EPA ID # #of TANK'# <br /> RESEATIONF-1 1 GAS STATION � 3 FARM �`�OTHER TRUST LANDS tl ❑ --���' AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) E RGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ;DAYSS pNAM LAST,FIRST) C/ d PHONE#WITH AREA COD <br /> 27. A7L.t(`' 7J <br /> �Ci-'A .' - _ �- dlcfV - oY�I I(/D — Gx) <br /> NIGHTS'. NAME(I-AST,FIRST) PHONE#WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> c^ �3a 2 11 H- ' e u-c - 33-5 3 0 <br /> II. PROPERTY OWNER INFORLIATION &ADDRESS,— (MUST BE COMPLETED) <br /> NAME --77 CARE OF ADDRESS INFORMATION <br /> #J <br /> M G or STREEESS ✓ ox to Intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> • L ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CI, AME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ds��3 0 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> :- _— <br /> M INC or STREET DRESS ✓CORPORATION <br /> 0 PARTNERSHIP 0 STATE-AGENCY <br /> / CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> NAME ST TE ZIP CODE PHONE#,WITH AREA COD <br /> s?3 - d <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH jBOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. 111. <br /> THIS FORM HAS BE N COMPLE D U DER ENA EDF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> A LI T'S ME DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# D #of TANKS at SITE <br /> 3,ZO <br /> RRENT LOCAL AGENCY FACILITY IDM APP ED BY NAME PHONE#WITH AREA CODE <br /> M Z,S-� <br /> MIT NUMBER E PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSSUUS�TRACTr. SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 32V VES NO q 90 <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 /> FORM A(8-2-88) <br /> +/ DATA PROCESSING COPY l / <br />