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STATE OF CALIFOROA WATER RESOURCES CONTROL BOARD <br /> FORM W: ,° o <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> /Y 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 Z <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) a <br /> F ILITV/SITE NAME CARE OF ADDRESS INFORMATION <br /> lC M.E. /fes+ N <br /> PDDR SS NEAREST CROSS STREET ✓9m to i"Scalx El PARTNERSHIP ElSTATE AGENCr <br /> ❑ CASK) TION <br /> El ❑ BALAGENCV <br /> j�G�jD/ A/ ❑ INOIVIouAL ❑ couN ACENcr C" <br /> ISI CITY NA E STATE ZIP CODE SITE PHONE q,WITH AREA CODE <br /> �trar� CA 9 5202 -6-,q / <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PRqdSSOR ✓Box if INDIAN EPA ID # #of TANK'# <br /> F__] I GASSTATION [1] 3 FARM THEA TRUSTVANDSo ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> CaM M <br /> NIGHTS'. NAME(LAS FIRST) PHONE p WITH AREA CODE NIGHTS. NAME(LAST FIRST) PHONE 0 WITH AREA CODE <br /> C <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> N E CARE OF ADDRESS INFORMATION <br /> C_ <br /> MAILING or STREET ADDRES ✓Box t0 intlicale []'PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ DERAL-AGENCY <br /> 11INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY N E STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> N E CARE OF ADDRESS INFORMATION <br /> I <br /> MAILING or_5ETADDRESS ✓Box io intlicale PARTNERSHIP ❑ STATE-AGENCY <br /> Sr / ❑ CORPORATION ❑ LOCAL-AGENCY ❑�EEDERAL-AGENCY <br /> / ❑ INDIVIDUAL ❑ COUNTYAGENCY ✓ <br /> CITY ME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> CF} I g5 ZaZ n/dvUiE- <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. ❑ If. III. ❑ <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# ,;(.-)---7 #of TANKS of SITE <br /> d ol <br /> CUNDEgN�T LOCAL AGENCY FACILITY ID# APPROV BY NAME PHONE#WITH AREA CODE <br /> C�# 3 <br /> PERMIT NUMBER PERMIT APPR VAL D TE RMIT EXPI TION Ajk <br /> LOCAT107CODE CENSUS TRAC# SUPE I IDI RICT CODE BUSINESS PLAN FILED DATE FILED <br /> 0 -231// YES ❑ NO Z� <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(3-2-88) o <br /> I <br /> DATA PROCESSING COPY <br />