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STATE OF CALIFORIP WATER RESOURCES CONIMROARD ' <br /> FORM W: <br /> UNDERGROUND STORAGE TANK PROGRAM m0 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE `'l110 <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE IV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE , Q' <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> CD <br /> ADDRESS NEAREST CROSS STREET 1/30emvaiate Cl PAWN63SHIP ❑ STATE AGBILY <br /> 3 / C` Cl ClLOCALAGENLY ClFEDERAL-AGENCY <br /> G• ❑ 'NONIIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> bC .N CA 9520` ,20 - t,-Op(� <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑d PROCESSOR ✓Bax if INDIAN EPA ID x <br /> RESERVATION or a of TANK's <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boa to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Sox twoocate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,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. 1. [�] 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 M JURISDICTION N AGENCY* FACILITY ID a N at TANKS at SITE <br /> s <br /> CURRENT LOCAL AGENCY FACILITY 10 a APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> ry�\ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS3TRACT a SUPERVISOR-DISTRICT CODE BUSINESSN FILED <br /> YES E] NO ❑ ///VVVIII <br /> DATE FILED � ` <br /> PERMIT AMOUNT SURCHARGE <br /> .AMOUNT FEE CODE RECEIPT 8Y: \��� <br /> M <br /> ORM MUS E ACCOMPANIEq AT LEAAT(1)08 MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> �'� DATA PROCESSING COPY L• J <br />