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1,,.T �►"_.w �"'r1,iNff(EYtI�P: -..#aP.... 'TfSFrY'"""Imp7NF'°•s.. <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> 54I !ti <br /> A : <br /> � 1 <br /> FORM ' <br /> : <br /> UNDERGROUND STORAGE TANK PROGRAM = " " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> CCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE PV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 'm <br /> r <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) V <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> I <br /> ADDRESS NEAREST CROSS STREET ✓BM ID roct ❑ PA8INEPBHIP ❑ STATE-AGENCY <br /> ❑ ODWOMTION ❑ LOCAL AGENLY ❑ FESERAL-AGENCY <br /> El 1 13OMM AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS. ❑ 2DISTRIBUTOR ❑ IPROCESSOR ✓Bos if INDIAN EPA ID # <br /> ❑ TANKs <br /> 1 GASSTATION ❑3 FARM ❑ 5 OTHER TRUSTVLANDS ATION or ❑ #of HIS SITE <br /> AT THIS STE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRSTI PHONE#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 /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to,rdicate ❑ 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 /> Ill. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inEicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STgTE ZIPCODE PHONE#,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# JURISDICTION# AGENCY# FACILITY ID It If of TANKS at SITE <br /> = zq <br /> CURRENT\LOCAL AGENCY FACILI ID* APPROVED BY NAME PHONE#WITH AREA CODE <br /> ill S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> — 1 � jztols)n <br /> LCHECK# <br /> DE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 2Zj.W 3Z YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY. \\e T <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(3-2-88) <br /> D �+—� DATA PROCESSING COPY <br />