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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD a "' <br /> �sa <br /> FORMA': °�`°��= . "gym <br /> UNDERGROUND STORAGE TANK PROGRAM = " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� <br /> 9' gin <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �°��ssea" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE fV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0) <br /> 6T1 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/ E CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ ox to udoile ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 522 S. ACORPORAT/I 11 IINDNIDUALION COUNTYAGENCY FEDERALAGEN <br /> CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> ti CA 6 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID 4 <br /> RESERVATION or #of TANK's <br /> ❑ 1 GAS STATION [_] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS. NAME(I-AST.FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS A�' f ox to"'d -to ❑ PARTNERSHIP ❑ STATEAGENCY <br /> 26326 S, A47A//&Q ;iI NORVIDRALION EJ COUNTY-AGENCY <br /> AGENCY LOCAL AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> Q <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 4 I <br /> MAILING or STpEET ADDRESJ ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> S (/(�JC{L ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> Mfg Ci4 3,6 <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. r 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID IF IT of TANKS at SITE <br /> 0 13 1 1 1 1 W <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> _ a c7�C <br /> PERMIT NUM ER `APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA`ON CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> .23>Z 3 YES NO <br /> CHECK AT PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <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 /> FORMA(3-2-88) <br /> `� I `%%.A DATA PROCESSING COPY ++' <br />