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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> G <br /> ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY El 1 NEW PERMIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ) <br /> 9 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> AGILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 5 IJ LMJL2,9 7,q SUW12f ST �"IAG O ry <br /> NEAREST CROSS STEER �AGGEA 9N ❑ LOCALAGEIG❑ �ERALABENCY <br /> Ln <br /> ADDRESS W <br /> I � ❑ INOIVIDL'AL ❑ CCUNIYAGENCY <br /> STATE ZIP CODE SITE PHONE#.WITH AREA DE <br /> CUV NAME CA 20 q4 -023 20 <br /> TYPE OF BUSINESS2 DISTRIBUTOR 4 CESSOR ✓Box if INDIAN EPA ID 4 n.' #of TANK's <br /> ❑ [_] RESERVATION or ❑ l'iw AT THIS SITE <br /> ❑ I GAS STATION ❑ 3 FARM [VrS OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> ONE 9 WITH AREA TCO,DE <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST.FIRST) <br /> DD PHONEN WITH AREA CODE <br /> NIGHTS. NAME(LAST. IRST) PHONE B WITH AREA CODE NIGHTS. NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NA <br /> MAILING or STREET ADDRESS <br /> I/Box to indicate D PARTNERSHIP 71STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY O FEDERAL-AGENCY <br /> qOO <br /> L INDIVIDUAL COUNTY-AGENCY 4 <br /> WI <br /> STATE ZIP CODE 1 AREA CODE <br /> CITY NAME �3 <br /> 3 <br /> K v <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME-�f��; <br /> IEIFx1CJ "r"�.WS <br /> ✓Box F,,odcate D PARTNERSHIP El STATE AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION D LOCALAGENCY ❑ FEDERAL AGENCY <br /> D INDIVIDUAL ❑ COUNTYAGENCY <br /> L�I�) STAT4 ZIP CODE PHONE a WITH AREA CODE <br /> CI�AME 9 <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. ❑ 11. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION k AGENCY# <br /> FACILITY ID k #of7aTE <br /> 0 pBYNAME PHONE# <br /> RRENT LOCAL AGENCY FACILITY 10# <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> DATE FILED <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED -7/��QQ <br /> O !� YES NO ❑ E <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp <br /> 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 ONLY. <br /> FARM A(3-2-88) <br /> DATA PROCESSING COPY <br />