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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA : UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACHFACILITY/SITE <br /> 11 <br /> MARK ONLY F__] I NEWPERMIT F-13 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDPERMI7 ❑6 TEMPORARY SITE CLOSURE �JJ T <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> COJwfa <br /> h44- <br /> '. ^ NEAREST CROSS STREET ✓ilmlpindoile 0 PARTNOWIIP 0 STATE-AGENO <br /> 30pp��/�/� WW (Jb v o INNDDNIDUALPORATI0N o NAG.AEENjCY 0 FEDETW-.AGEIILY <br /> CITY NAME LSTATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR I ✓Box if INDIAN EPA ID a <br /> RESERVATION or M of TANK'N <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5OTHER TRUST LANDS ❑ AT THIS SITE <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(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS' NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS JBox to inmeate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> _ 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ II. ❑ 111.❑ <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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> 1 0 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT cN� SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> �.� -OV �2 YES NO -To Q <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> ^ THIS FORM MUST BE ACCOMPANIED BY AT LEAS'al OR MORE TANK PERMIT FORM 'B'APPLICATION(S),IP"ESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A 2-88}1 <br /> DATA PROCESSING COPY `� <br />