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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD . h` OF <br /> FORM IA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION O <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> CIlOP- i -A <br /> ADDRESS NEAREST CROSS STREET ✓gpxp� D IMINEORIP D STATE AoE <br /> DCORPOWON Cl LOX AGENCY Cl IEDEPA A03Cf <br /> D INDVIWAI D O MfY-AGENLY <br /> CIN NAME STATE 21P CODE SITE PHONE 4,WITH AREA CODE <br /> NC CA Q - <br /> TYPE OF BUSINESS: ❑ @ DISTRIBUTOR A PROCESSOR ✓Box if INDIAN EPA ID # •W TANK'S <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTRESERYATION LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a� N� <br /> NIG AME(LAST.FIRST) PHONE N WITH <br /> AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> s T 92—5 / <br /> II. PRO ERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFO ATIN <br /> �as� , a ' <br /> MAILING or STREET ADD ✓Bo intlicate O PARTNERSHIP D STATE-AGENCY <br /> O j� RPORATION D LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> / INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME ST ZIP CODE PHONE N,WITH AREA CODE <br /> Aac <br /> III. TANK OWNER INFORMA ION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Jr.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ Il. 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 R JURISDICTION R AGENCY# F R of TANKS at SITE <br /> 3Cl L I L-/ r I <br /> CURB CAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> f <br /> PERMIT PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDOATS FILED <br /> —2 7 t� YES NO 2 (� <br /> CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT AMMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> l <br /> FORMA 13-2-8 <br /> SI \ <br /> S- 3a q D <br />