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-STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> ORM W: '� �" Z <br /> F UNDERGROUND STORAGE TANK PROGRAM � ,° 10 <br /> EMARK <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> ❑ 7 PERMANENTLY CLOSED SITE 1"a <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION � <br /> ONLY ❑ ❑ 6 TEMPORA--SITE CLOSURE a) <br /> ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 0 <br /> FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) C <br /> CARE OF ADDRESS INFORMATION <br /> FACI ITY/SIT NAME <br /> d NEAREST CROSS STREET O B IRPOOWRO 0 LA�E�IPS O �E AGENU <br /> I <br /> ADDRESS <br /> W_ ❑ INDMOU4 ❑ WUNTf AGENCY i <br /> ISTATE ZIP CODE SITE PHONE p.WITH AREA CODE <br /> Cl/tt/NAME CA S 2 <br /> EPA ID a If of TANK's <br /> TYPE OF BUSINESS: ❑2 STRIBIJTOR ❑<PROCESSOR V Box if REINDIAN <br /> SERVATION or ❑ AT THIS SITE <br /> ❑I GMMSTATION 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE p WITH AREA CODE <br /> '. PHONE p WITH AREA CODE NIGHTS: NAME(LAST FIRST) <br /> PHONE M WITH AREA CODE <br /> NIGHTSNAME(LAST.FIRST) <br /> �. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM / CARE OF ADDRESS INFORMATION <br /> 3 <br /> MAILING or STREET ADDRESS ✓Box to indicate [I PARTNERSHIP ❑ STATE-AGENCY <br /> 11 CORPORATION 01LOCAL-AGENCY ClFEDERAL-AGENCY <br /> Cl INDIVIDUAL [ICOUNTY-AGENCY <br /> STATE 21P CODE PHONE N.WITH AREA CODE <br /> CITU NAME <br /> 11. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED)SS MAnoN <br /> [NAME! as CARE OF T ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 7 ❑ CORPORA TION 0 COUNTY AGENCY ❑ FEOERAL-AGENCY <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 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. LJ III.U <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> onrE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> (LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION K AGENCY M FACILITY ID N K of TANKS al SITE <br /> FEU <br /> CURRENT LOCAL AGENCY FACILITY ID M� <br /> APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER LPU 5 PERMIT APPROVALDATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CE^US TRACT N SUPERVISOR-DI CODE BUSINESS PLAN FILED DAT F ED <br /> L3 23 YES E] NO <br /> CH K PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT K BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM V APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />