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STATE OF CALIFORM . WATER RESOURCES CONTROL BOARD f <br /> FORMA% �av�� • <br /> UNDERGROUND STORAGE TANK PROGRAM = ' Fit4 " <br /> SITE — FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE �,�,•o <br /> FMARK,CNLY F-11 NEWPERMIT E] 3 RENEWALPERMITHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> EM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> r� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS T// � Q� NEAREST CROSS STREET I/Ba 0 Mcaa ❑ PARTNERS10 ❑ STATE AGENCY <br /> 3/33 / /Yl 1:1 CORPOMTiON 0 LOCAL AGENCY 0 FEDERAL AGENCY <br /> ❑ INDIVIDUAL Cl COLwnAGENCY <br /> CITY NAME �^ STATE ZIP CODE SITE PHONE A,WITH AREA CODE <br /> �� /0I CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 PROCES50fl ✓Rox'INDIAN EPA 10 A <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYANDS or ❑ N of <br /> AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Eox to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,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 ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,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. ❑ it. ❑ 111. ❑ <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 /> COUNTYA, JURISDICTION N AGENCY k FACILITYJD-4P a of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> VES ❑ NO E:] 6 SSL <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Ar I I e <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 /> FORM A(3-2-88) <br /> Li HROCESSING COPY <br /> V <br />