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SATE OF CALIFORKmAA WATER RESOURCES C014'VI45L BOARD <br /> ORM W: <br /> SITE UNDERGROUND STORAGE TANK PROGRAM m" <br /> FACILITY/SITE, INFORMATION and/o PERMIT APPLICATION ® <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION pe` <br /> ONE ITEM 2 INTERIM PERMIT ❑ 7 PERMANENTLY CLOSED SITE <br /> ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FADDRESS <br /> /SITE NAME <br /> _ CARE OF ADDRESS INFORMATION <br /> 0 <br /> O N S <br /> C^ NEAREST CROSS STREET ✓BD�p�,pyy, � Ip ❑ STATE.AGBAX <br /> �JL�(�(J ❑ ODRPORATM Ley«.dx1uN-EAgG$ENxc+ ❑ FEOERk AGOCY <br /> E ' Ixd ❑ NGMGIIk CJ CD'JNIY-,IG�� STATE ZIP CODEWITH ARA CODE <br /> BUSINESS CA �(7 <br /> ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box I INDIAN EPA ID N <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER RgIS/SRTYATION LANDS or ❑ Mol TANK1 <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY 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 /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTYAGENCYCITY NAME STATE ZIP CODE PHONE p,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 CSTATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE 21P CODE PHONE p,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. ❑ III. ❑ <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 If SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION k AGENCY S FACILITY ID M E of TANKS N SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED.BY NAME PHONE F WITI4 AR CODE <br /> k5� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> Zc�/TPER AMOUNT SURCHARGE AMO FEE CODE YES <br /> NO <br /> CHECK ❑ B <br /> 3THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS M A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-80) / ` <br />