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STATE OF CALIFORNIA• WATER RESOURCES CONTROL BOARD '"'' <br /> FORM W: u, <br /> UNDERGROUND STORAGE TANK PROGRAM �_o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITYISITE NAME _ CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓RNbldale D PANTNERSIMP 0 STATE AGENW <br /> D caP0FATM ❑ LOCA-AGOO ❑ FEDEWAGENLY <br /> `T KGC D NiID COUNTY AGENC! <br /> CITY NAME STATE ZIP CODE SITE PHONE p.WITH AREA CODE <br /> CA 9,53 <br /> TYPE Of BUSINESS: ❑2 DISTRIBUTOR /PROCESSOR ✓Box it INDIAN EPA ID p <br /> RESERVATION or N of TANK'p <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ S OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE p 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 or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,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. ❑ I. ❑ IT.❑ <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 N JURISDICTION M AGENCY N FACILITY ID N N of TANKS N SITE <br /> 3 9 = = I I 1 ZZs / & <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DAIX <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> d YES CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE ❑RECEIPTI ❑ BY: <br /> d <br /> l <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I ORE TANK PERMIT FORM 'B'APPLICATION($), UNLFTHIS IS A CHANGE OF SITE INFORMATION ONLY. } <br /> � FORM A(3-2-B5) ( <br />