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STATE OF CALIFORNIA"i WATER RESOURCES CONTROL16ARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �"`�""�� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) wwwW <br /> FAC IL /SIT�E!N�A/ME J�. CARE OF ADDRESS INFORMATION w �I <br /> ADD ESS NEAREST CROSS STREET ✓Bor.birarae ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> L / /� E7 0DWORATO ❑ Lau-AGENCY ❑ FmDwAGRO <br /> .I (� Glq ❑ INDMIDUAL ❑ 00VIT(AGENCY <br /> CITY A E STATEZIP ODE SITE PHONE#,WITH AREA CODE <br /> G CA <br /> TVPEOFBU NESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR RESERVATIONor EPA 10 a #of TANW2 I� <br /> 1 GAS STATION ❑3FARM ❑ 5OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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 ZIPCODE 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. ❑ it. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COOJU�N�TTY# JURISDICTION a AGENCY# FACILITY ID a #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE#WITH AREA CODE <br /> 03 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DAE <br /> -LOCATION CODE CENSUS TRACT SUPERVISOR-DIST ICT CODE BUSINESS PLAN FILED DATEFI D <br /> �n/ 3 , Ik <br /> YES // / <br /> HECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTa� BY: <br /> ATHIS FORM MUST BE ACCOMPANIED BY AT LEAST f1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IIS A CHANGE OF SITE INFORMATION ONLY. <br /> j ORM A(3-2-88) i <br /> 1.r DATA PROCESSING COPY - <br />