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,gyp t1 /• mt�.,�•� <br /> STATE OF CALIFORNIl9 WATER RESOURCES CONTROL BOARD <br /> R. f1 <br /> FORM `AI: ° <br /> SITE UNDERGROUND STORAGE TANK PROGRAM =mom <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o : Z <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE I <br /> CM I,fORN\P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANG�SITE <br /> ION <br /> ONE ITEM ❑ T PERMANENTLY CLOSED SITE I'+ <br /> ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPOURE �3 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) w <br /> W <br /> FACILITY/SITE NAME L 00 e CARE OF ADDRESS INFORMATION <br /> S <br /> ADDRESS <br /> p NEAREST CROSS STREET ✓Box b ❑ PARTNERSHIP ❑ STATE.AGENLY <br /> CITY NAME &ZWNL INOYIOWL� ❑ Nry0 LOCAL ApCY ❑ � <br /> STATE ZIPCODE SITE PHONE At WITH AREA CODE <br /> TYPE OF BUSINESS' ❑2 RIBUTOR ❑d PROCESSOR ✓Box if INDIAN EPA ID #A ' —` '/96Y <br /> 1 GAS STATION 3 FARM ❑ 5 OTHER RESETRUSRVATION or ❑ N of TANK'F <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY)FIRST <br /> DAYS: NAME(LAST,FIRST) PHONE#WqfFITH AREA CODE DAYS: NAME LAST, <br /> ( I PHONE p WITH AREA CODE <br /> NIGHTS: NAME, FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> .� h1'e GS .Y/ <br /> MAILING or STREET ADDRESS ✓Box to o0cate ❑ 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 /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to iritlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE 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. 1L ❑ 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 /> COUNTYIN JURISDICTION Is AGENCY# FACILITY ID# It of TANKS at SITE <br /> CURRENT LOCAL AGENCY F ILITY IDM APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA3QN CODE I CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILE <br /> 2 � YES ❑ NO ❑ 6 C <br /> CHECK# PERMIT AMOUNT BURG qGE AMOUNT FEE CODE RECEIPT N BY: <br /> I / 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 /> 1�(V FORM A(3-2-BB) <br /> DATA PROCESSING COPY <br />