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SE'T.0 ail '�f <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': ��� _ <br /> UNDERGROUND STORAGE TANK PROGRAM = " _ We <br /> SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONZL <br /> C� COMPLETE THIS FORM FOR EACH FACILITY/SITE 1�oe"-`�'' , L C <br /> MARK ONLY ❑ 1 NEW PERMIT Fl 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T NTLY CLOSED SITE IN <br /> ONE ITEM 2 INTERIM PERMIT E] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE a <br /> v <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> I! /0 7 <br /> ADDRESS / NEAREST CROSS STREET ✓SMbrdrtle ❑ PARINJIBW ❑ STATEJSBI,Y <br /> ( 17 t ❑ CGWOAITON ❑ LOCAAGDO ❑ Ff0EN4 <br /> ❑ HNINVIL. ❑ ODNTY.A000 <br /> CITY NAME w STATEJ` ZI /� SITE PHONE I,WITH AREA�6 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR I -/Be.A INDIAN EPA ID x <br /> E] ❑ ❑ RESERVATION or ❑ A T <br /> 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS AT THIS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE It 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 m STREET ADDRESS ✓Be.to indicale ❑ 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 /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bodo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ 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. D 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 W JURISDICTION# AGENCY N FACILITY ID M K of TANKS at SIT <br /> 5 z <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA C_O <br /> / n / � <br /> pt <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRA � SUPER{II OR-0IfTRI CODE BUSINESS PLAN FILED DATE FILED <br /> f� 71 VES NO <br /> CHECK* PERMIT AMOUNT SURCHA EAYOU I FEE CODE RECEIPT# BY: /- - <br /> THIS FORM MUST BE ACCOMPANIED BY AT I-se*11)OR MORE TANK PERMIT FORM 'S'APPLICATIONIsI.IINLESS THIS IS A CHANGE OF SITE INFORMATION ON - <br /> FORM A(3-2-BB) <br /> �-'' DATA PROCESSING COPY ""�'� <br />