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STATE OF CALIFORNIA"' WATER RESOURCES CONTROL`fOARD <br /> FORMA': <br /> SITEUNDERGROUND STORAGE TANK PROGRAM u " <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �,A,���,P c h <br /> MARK ONLY ❑ 1 NEW PERMIT Ej 3 RENEWAL PERMIT LVJ 5 CHANGE OF INFORMATION <br /> ONE ITEM 2 INTERIM PERMIT El 2 PERMANENTLY CLOSEDSITE NJ <br /> 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE L O': <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) v 07) <br /> FACILITY/SITE NAME (T <br /> CARE OF ADDRESS INFORMATION <br /> QTY OS1� <br /> ADDRESS <br /> NEAREST CROSS STHE B.loiMirale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> o /O� ❑ CORDO TION ❑ LOCAL AGENCY ❑ FEDERALAGENCY <br /> CITY NAME r ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> STATE ZIP CODE SITE PHONE b/,+WITH AREA CODE <br /> TYPE OF BUSINESSCA <br /> E 2 TRIBUTOR E] 4 PROCESSOR I/Box if INDIAN EPA ID a <br /> E] I GAS STATION FARM 5 OTHER RESERVATION ora of TANK's <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) - a PHONE#WITH AREA CODE AV <br /> DAYS: NAME(LAST FIRST) <br /> PHONE ft WITH AREA CODE <br /> NIGHTS:7NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NgME(LAST FlRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME . CARE OF ADDRESS INFORMATION <br /> /l ar►Y a re <br /> MAILING or STREET ADDR ✓BOx Ia,,c,cale Cl PARTNERSHIP ElSTATE-AGENCYZ SJ� ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> L iaolw,� C 5p 36 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box lOierlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 11 INDIVIDUAL ❑ COUNTYAGENCYCITY 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. Fj if. 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 If AGENCY# #of TANKS BI SITE <br /> C I I � 13 1 - " I t=1:0_ <br /> CURREN AGENCY FACILITY ID# APPROVED BY NAME PHONE#NRTH AREA CODE <br /> VJ _ <br /> PERMIT NUMB OVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FI D <br /> YES NO � <br /> CH C # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODEgECEIPT# BY: <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 ONL'(.— <br /> FORM A,3-2 11, <br /> \J <br /> .0[J�O DATA PROCESSING COPY <br /> �D— <br />