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i <br /> iI <br /> OF CALIFORNIAWATER RESOURCES CO E ROLIBOARD <br /> ORM: _ <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SST FACILITYISITE, INFORMATION and/8r PERWT APPLICATION <br /> `Rt FORS P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SIYE!E `-- <br /> i ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑�9NJAENTLY CLOSED SITE <br /> =,MPARK ❑ t NEW PERMIT ((}}f�❑2 INTERIM PERMIT 4 AMENDED PERMIT <br /> G TEMPORARY SITE CLOSURE G <br /> I. FACILITY/SITE INFORMATION & ADDRESS --- (MUST BE COMPLETED) . <br /> CARE OF ADDRESS INFORMATION <br /> FACILITYISITE NAME > 1 01 / it <br /> NEAREST CROSS STREETol Cl poME�� 0 FEEERAI-AGENCY <br /> { <br /> ADDRESS , i' I { f,v W_G(S v�, i G _ Q INDNIDUAt ❑ cauNrrACENcr <br /> STATE ZIP CODE�f y SITE PHONE#,WITH AREA CODE <br /> f1 CITY NAME S-.�z CA G �2v�7 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 E551 ✓Bux it INDIANEPA IDN If of TANK" <br /> AT THIS SITE <br /> RESERVATION Or p` <br /> 1 GAS STATION ❑ 3 FARM N111,5'' <br /> OTHER TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> EMERGENCY CONTACT PERSON(PRIMARY) ;' PHONE M WITH AREA CODE <br /> DAYS: NAME(LAST.FIRST) PHONE M WITH AREA CODE DAYS. NAME(LAST•IFIRST) <br /> ICe t i It- ( c. — �� .�9t-ft <br /> NIGHTS, NAME(LAST.FIRST) <br /> PHONE M WITH AREA CODE NIGHTS; NAME(LAST,FIRST) <br /> ,f PHONE p WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION &ADDRESS -- (MUST BE COMPLETED) <br /> CARE OF ADDRESS'I}rNFORMATION <br /> NAME e �� 1," �I <br /> MAILING or STREET ADDRESS x[o mdicalie ❑+ PARTNERSHIP - El SIA TE-AGENCY <br /> �U ,CORPORATION <br /> ❑ El LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL'f i] COUNTY-AGENCY j <br /> CITY NAME STATE' I ZIP CODE PHONE M,WITH AREA CODE <br /> Ili. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Q5EDFR�AL-AGENCY <br /> �'�` U �• tti _I- G/ ❑ CORPORATION ❑ LOCAL-AGENCY IL� l� lG ( INDIVIDUAL ❑ COt3NTY-AGENCYSTATE ZIP COpE PHONE �/JCITY NAMECJ.� <br /> liL i <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE AMR93S SHOULD BE USED FOR MOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ ill.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF,1 MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> I DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY J <br /> COUNTY K JURISDICTION k AGENCY M FACILITY IDN M of TANKS of SITE <br /> LI <br /> F •1 <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATA PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS <br /> SS PLAN FILED DATE FILED <br /> YES NO <br /> .i CHECK M PERMIT AMOUNT SURCHARGE AMOUNT - FEE COO£ i '` RECEIPT• BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST AMORE TANK PERMIT FORM '8*APPLICATION(S), UP' -� THIS IS A CHANGE OF SITE INFORMATION ak(Y. <br /> /1 <br /> °-A.," •FORM A;3-2-B8) <br />