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STATE OF CALIFORNIA " WATER RESOURCESCONTROL*ARD <br /> LtPI <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM )^ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE IQ <br /> MARK ONLY El'T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION _] 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION v <br /> E rJ <br /> ADDRESS NEAREST CROSS STREET ✓Box to indcale ❑ PARTNERSHIP C STATE AGENCY <br /> 3 '�� ❑ CORRTUTION ❑ LOCAL AGENCY C FEDERk AGENCY <br /> ❑ wDmUAL ❑ COUNTY AGENCY <br /> CIN NAME STATE ZIP COE SITE PHONE N,WITH AREA CODE <br /> CA CJ, <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IO 1 <br /> 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTLANDS <br /> ATION of ❑ #of TANK'F <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LA$T,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> s 'I lu H✓Mp <br /> MAILING or STREET ADDRESS -/60.to intlicate C PARTNERSHIP C STATE-AGENCY <br /> '—— C CORPORATION C LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE RHONE#,WITH AREA CODE <br /> n6 Z x-13 (o - <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP C STATE-AGENCY <br /> C CORPORATION C LOCALAGENCYC FEDERALAGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONEY WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> C <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERV1 7R-DISTRICT CODE BUSINESS PLAN FILED DATE FILE G <br /> YES NO I Z / O <br /> CHE K N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(P^Q MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY C^ <br /> FORM A(3-2-88) C-\ loomJ <br /> DATA PROCESSING COPY <br />