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STATE OF OALIFORNIN WATER RESOURCES CONTROL BOARD <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE �FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITEi4 <br /> `'A,ro <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EADIftlNOE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 <br /> - 1 <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) CD <br /> FACILITY/SITE NA ^ to <br /> CARE OF ADDRESS INF MATION <br /> 'Vo <br /> ADDRESS ^ NEAREST CROSS STREET ✓Bpx WcO? ❑ PARTNERSHIP ❑ STATE AGENCY <br /> /✓� I O�� ( ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> n e Lcl CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA 10 a <br /> F—] I GAS STATION F-13 FARM ❑ A <br /> 5 OTHER TRUST LANDS ESEVATIONo ❑ of <br /> AT THHISIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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 <br /> Cl PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ 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: 1. ❑ it. ❑ 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 R JURISDICTION N AGENCY M FACILITY ID M N of TANKS at SITE <br /> 0 5 a o U <br /> CURRENT LOCAL AGENCY FACILITY ID M �I !SUPIERVISOR-DISTRICT <br /> o3(, APPROVED BY NAME PHONE a WITH AREA CODE <br /> PERMIT NUMBER PERMIT AE PERMIT EXPIRATION DATE <br /> LOCA T I E CENSUS TIIACTM CODE BUSINES;P SN❑FILED NG ❑ DATE FI ED9 <br /> CHECKk PERMIT AMOUNT l„J` AMOUNT FEE CODE RECEIPT N BY: <br /> JRHM <br /> 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 /> (3-2-SB) • • <br /> DATA PROCESSING COPY <br />