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STATE OF CALIFORNIA ... WATER RESOURCES CONTROL BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM u �' <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ACOMPLETE THIS FORM FOR EACH FACILITY/SITE o " <br /> MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL CLOSEDSITE W <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) OD <br /> FACILITY/SITEAME NCARE OF ADDRESS INFORMATION <br /> C <br /> ADDRESS NEAREST CROSS STREET ✓ft to mom 0 PAIRNBSIP D STATE-AGENCY <br /> O 1 /. f /� ❑ CORPDRAT10N 133LOCAL-AGENCY [IFEOEFK-AGENLY <br /> �(Ms I`///��� ❑ iNDWIDUa ❑ MNTAGEICY <br /> CITU NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS. ❑ p DIST IBUTOR ❑ 4 PROCESSOR ✓Box A INDIAN EPA 10 N <br /> F-11 GAS STATION ARM El5 OTHER RE <br /> ST ANDS oRVION f 1-1k of TANKS <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 11 nC <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> HT <br /> STATE [Y ZIP CODE PHONE k,WITH AREA CODE <br /> / C f3 -5 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S C.(i✓� <br /> MAILING or STREET ADDRESS ✓ o inotcate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> ORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 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. ❑ IN.❑ <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 /> COUNTY k JURISDICTION If AGENCY 8 FACILI If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY O J�/y PROVED BY NAME PHONE WITH AIREA CODE <br /> PERMIT NUMBER _7107-APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOC N CODE CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3 , (03 YES ❑ NO ❑ <br /> CHEG N PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPTN . <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 /> DATA PROCESSING COPY <br /> 0 -- <br />