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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD "�°' "' <br /> FORMA% UNDERGROUND STORAGE TANK PROGRAM (%i <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONILL �� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `�"=�� F7/ <br /> MARK ONLY ❑ 1 NEW PERMIT F__] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE E/N LOSED SITE t 1 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME — CARE OF ADDRESS INFORMATION W <br /> ADDRESS NEAREST CROSS STREET ✓8ativ rm ❑ PARTNERSINP ❑ STATE AGM <br /> (jL / ,yam ❑ WRORATION 11LOCAL AGENCY EIFEDERAL-AGENCY <br /> ( f�� / O� !h ❑ INDNIDUAL ❑ 001 AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> l/ CA / <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR I -/Box if INDIAN EPA ID x <br /> RESERVATION or #of HIS SI <br /> ❑ 1 GAS STATION ❑3 FARM E] 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE if WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#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 /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I.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 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. ❑ Ill. ❑ <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# JURISDICTION Of AGENCY# FACILITY ID# It of TANKS at SITE <br /> Cil I 1 11161y <br /> CURRENT LOCAL AGENCY FAC TY I APPROVED BY NAME PHONE#WITH AREA CODE <br /> $A-I� OSS <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> /1 <br /> q yv YES [-] NO <br /> CHECK _1 PERMIT AMIO/UNT SURC RGE MOUNT FEE CODE RECEIPT# BY:/ p <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM BY APPLICATIONS` I INLESS THIS IS A CHANGE OF SITE INFORMATION <br /> \ FORMA(3-2-51 <br /> DATA PROCESSING COPY y✓/ ^ <br />