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STATE OF CALIFORNIA WATER RESOURCES CONTROARD uP � i <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM = � I <br /> Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El7 PERM LV CLOSED SITE <br /> ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a) <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) to <br /> FACILITY/SITE NAA9E CARE OF ADDRESS INFORMATION <br /> ADDRESS O I , NEAREST CROS�STREEET Yto imme ❑ PARLOGTNERSHIP ❑ STATE AGENCY <br /> I 0 t /I 6 /�^ �� p'�O� ❑ pry DUAIGN ❑ COUNTY AGENCY <br /> Al AGENCY [I FEDERAL AGENCY <br /> CITY NAME �V VV�'C/V v _ STATE ZIPDE�� O SITE PH NN El L=N,WITH ARFA=OOE <br /> 570 °✓ CA � 9 <br /> TYPE OF BUSINESS: ❑ 2DISTRI6UTOR ❑4 OCESSOR ✓Box i(INDIAN EPA IDa Not TANK'# <br /> RESERVATION or ❑ AT THIS SI7E <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> GAYS: NAME(LAST,FIRST) —� 'IZ31 C { <br /> NIGHTS'. NAME(LAST, RS I <br /> PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME /� <br /> U�>O,� �� C/V (�' ✓ ox tointlicate ❑ PARTNERSHIP77]] <br /> MAILING or STREET D RES 5kt- �� CORPORATION ❑ LOCAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCCITU NAME / STATE ZIP COD �O PHONE p,WITH ARE <br /> Q PSI C/�� (_fir Z <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME Ili / CARE OF ADDRESS INFORMATION <br /> MAILING or ST ET ADDRESS ` Lo indicate ❑ PARTNERSHIP ❑ STATEAL AGEENCV <br /> 01 / O n' CORPORATION 0LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 4Y INDIVIDUAL Cl OOUNTY-AGENCY <br /> CITY NAME <br /> ZIP��/'j PHO W A ODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)SOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El it. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# #o1 TANKS at SITE <br /> HT1 n� s 7 ffO <br /> L31JAPPROVED BY NA PHONE N WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> PERMIT NUMBER \ PERMIT APPROVAL DATE � / PERMIT EXPIRATION DATE <br /> 9 <br /> LOCATION CODE CENSUS TRACT] SUPERVISOR-DISTRIC CODE BUSINESS PLAN FILED NO ❑ DATE FILED <br /> 2 M lNT RECEIPT# BY: <br /> GHEGKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1) MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-SS) <br /> DATA PROCESSING COPY <br />