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STATE OFC ALIF'ORNIA,_./ WATER RESOURCES CONTROL-Ii4OARD yn�°��;'�� <br /> FORA `A': / ) UNDERGROUND STORAGE TANK PROGRAM �a� Z <br /> SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH�ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PER NEN �q ITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) I tV <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> LAN P ftf- 84Q <br /> ADDRESS ( NEAREST CROSS STREET B0 OwmnoN ❑ LOC -Aucr ❑ mxwwaZ <br /> ❑ Immik ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA Jr 76 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if NDIAN ' EPA 10 N <br /> If of 1 GAS STATION ❑3 FARM 5 OTHER TRUSESET LANDS ATION or ❑ AT THIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME ST,FIRST) PHONE#WITH AREA COO NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROP,ERTY,dWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> yAMff �p d CARE OF ADDRESS INFORMATION <br /> 444t,&96��9�D 146ttil) OAk C)j2W,9;,All( <br /> MAILING or STRE DDRE ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> /I� CORPORATION Cl LOCAL-AGENCY ClFEDERAL-AGENCY <br /> TT Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> b -- T410-36 - 60-IDIJ <br /> I11. TANK OWNER INFORMATIO ESS — (MUST BE COMPLETED) <br /> NAME ARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME - STATEZIP CODE PHONE#,WITH AREA CODE <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. ❑ 11. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION S AGENCY S FACILITY ID N 1f of TANKS at SITE <br /> 39 I gil F_oTo I vo <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE#WITH AREA CODE <br /> Y <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO �6 / <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUN'T FEE CODE =ECEIPT N BY: \ <br /> , wo (,l <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 />' ORM A(3-2-88) f LN <br /> DATA PROCESSING COPY /` <br />