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STATE OF CALIFORNI01 WATER RESOURCES CONTROi BOARD <br /> FORM `AN: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '°< 1 <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEWF(!RMIT ❑ 3 RENEWALPERMIT EB�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE }-y <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE / <br /> F <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CID <br /> CTI <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> A/D/Z 7- <br /> ADDRESS <br /> ADDRESS NEAREST CROSS STREET ✓fWN le ❑ PARTNERSHIP ❑ STATE AGENCY <br /> / <br /> E) CORPORATION Cl LOCAL AGENCY El FEDERAL AGENCY <br /> 7 f [�(�(/fy ❑ INDIVIDIIM ❑ CWNTI'-AGENCY <br /> CIN NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS'. ❑ p DISTRI86TOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N <br /> RESERVATION or N of TANK'N jl <br /> ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE C/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N 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 intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ 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 intlicale Cl PARTNERSHIP Cl STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY0 FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ II. ❑ If. ❑ <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 at SITE <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PIERNMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DALi <br /> YES NO 0 CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <br /> THISAF'y�O�+���RM 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 /> F `08) <br /> � 9 w DATA PROCESSING COP'! S <br />