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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> W <br /> FORM PAI: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE 1"A' <br /> ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE q W <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> v <br /> FACILITY/SITE NAME(� , I CARE OF ADDRESS INFORMATION <br /> in <br /> lieADDRESS a NEAREST CROSS STREET ✓BnfP,f MMcma ❑ PARrNERSHR ❑ FATEAGENCY <br /> /n �. 1,x 5/COHP%TION ❑ LOCAL AGENCY ❑ FEDERALAGENCY <br /> l �.l ✓✓✓ Y• ❑ INDIVIDUAL ❑ COUNT- <br /> AGENCY <br /> CITY NAME STATE ZIP DE SITE PHONE i H AREA CODE O <br /> S__rkl1L1 CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PIOCESSOR I/Box if INDIAN EPA ID a <br /> of TANK's <br /> ❑ 1 GASSTATION 3 FARM 5 OTHER RESERVATION or AT THIS SITE <br /> ❑ TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> NIGHTS: NAME(I-AST,FIR PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ox to intlicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMEsil- STATE ZIP CODE —� PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) S <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING or STREE DDRESS ✓Ban intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 I POTATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 4 DIVI DUAL ClCOUNTY-AGENCY <br /> CITY NAME 1 - STATE - ZIP CODE PHONE k,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. ❑ If. <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 N AGENCY N FACILITY ID M R of TANKS at SITE <br /> F5-T-ll = = 1010 / I 0= 0h01 <br /> CURRENT LOCAL AGENCY FACILITY ID K APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUMBER O INPERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO ODJ CENSUS TRACT SUPERVISOR-DITRLCT CODE BUSINESS PLAN FILED DATE FILED <br /> (/11 S 1//1 YES [] NO <br /> CHECK M PERMIT AMOUNT SURCHAFRIE AMOUNT FEE CODE RECEIPT♦ BCW Q <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-BB) <br /> DATA PROCESSING COPY � <br />