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STATE OF CALIFORNW"' WATER RESOURCES CONTROL BOARD <br /> FORM W: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or P RMIT APPLICATION - _ 10 <br /> COMPLETE THIS FORM FOR EACH,FACILITY/SITE CA(fp RNtP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5211's CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 -4 <br /> V1 <br /> 1.FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CO <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ ink& ❑ PM T%ISHIP ❑ STATE-AGENG( <br /> 7 GL 15 ElCOFMPWTION 0 INDDUAL LOCA-AUAc HEN Y ClFEOERAL-AGENO <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA p <br /> TYPE OF BUSINESS: EIBUTOR 4 PROCESSOR ox if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ❑ 1 GASSTATION 3 FARM ❑5 OTHER TRUST LANDS ❑ /VCIiV F 1ATTHISSITE C),2_ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FORST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME �w CARE OF ADDRESS INFORMATION <br /> Ca <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FFDFRAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓B indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> pRPpRAT10N ❑ LOCAL-AGENGY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDREU SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. ❑ Ill. <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 /> E <br /> JURISDICTION# AGENCY# F YID# #of TANKS at SITE <br /> N4Y FACILITY!D AP OVED PHONE#WITH AREA CODE <br /> PERMIT APPROY PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / <br /> 3 31.2111 YES ❑ NO ❑ Cr D, <br /> -)- <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($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOAM A(3-2-881 <br /> DATA PROCESSING COPY '�'� <br />