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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM s " <br /> SITE _ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION $m <br /> ' COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-` <br /> ONE ITEM 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE '4 <br /> l--& <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 00 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET I/as 10 W ❑ PMTWRSHP ❑ STATE AGEKL <br /> 11❑ NIDfOWOPATIIXI 1:1UNU 13 LOM O11.WIYAGENLY 0 FEEAHVI AGEIILY <br /> MAtCITY NAME _ STATE 21P CODE SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR /PROCESSOR ✓Box it INDIAN EPA IO p t�` <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS w ❑ AT THIS SITS <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 N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Box to ma,cale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Bax to inoicale Cl PARTNERSHIP 11 STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NA E STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEG L NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 /> COUNTY M JURISDICTION N AGENCY* FACILITY ID N R of TANKS at SITE <br /> 3y r51 <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE•WITH AREA CODE <br /> MA1ZCl� <br /> ECHECKI <br /> ERLPERMITAMOUNT <br /> ERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> DE SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE L <br /> I� YES NOE] ��� <br /> SURCHARGE AMOUNTFEE CODE RECEIPT 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 ON <br /> F A(3-2-BB) <br /> A,\1- DATA PROCESSING COPY <br />