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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD W �ss9 <br /> FORMA'" UNDERGROUND STORAGE TANK PROGRAM ' ! a o III <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C4lIFOR'!�P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 7 PERMANENTLY CLOSED SITE r <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION N <br /> MARK ONLY ❑ 5� oG <br /> ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ' 4 j <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> cn <br /> CARE OF ADDRESS INFORMA IN / <br /> FACIL / TE NAME ;f Y <br /> JCIiREST CROSS STREET ✓So�Ia irdirzle ❑ PAPTNERSHIP ❑ STATE AGENCY <br /> Cl CORPORATION ORAL Ci ❑ FEDERAIAGENCY <br /> ADDRESS ❑ COUNTY AGENCY <br /> 1 Y ❑ INDIVIDUAL <br /> STATE ZIP CODE (l SITE PHONE#WITH AREA CODE <br /> CITY NAME CA <br /> EPA ID p If of TANK'a <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ OPROCESSOR A/Box if INDIAN <br /> RESERVATION or AT THIS SITE <br /> I GAS STATION ❑ 3 FARM ER TRUST LANDS ❑ <br /> F-1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> ,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LASE FIRST) <br /> PHONE ft WITH AREA CODE <br /> DAYS'. NAME( ST <br /> �' wY <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COF oOMPLLETERESS oD) <br /> [NAMEE ((��l ✓Bax tointlicale ❑ P SHIP ❑ STATE-AGENCV <br /> DDRESS ❑ CORPORATION OCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL COUNTY-AGENCY <br /> ST1AnTE� ZIP ODEPHONE p,WITH AREA C00E <br /> r l. _ ' Sd �U a oq 333�� <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> ADDRESS AnoN <br /> [NAMEBox 10 Intlicale [IPARTNERSHIP ❑ STATE-AGENCV <br /> LING orSTREET ADDRESS [ICORPORATION [ILOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL C] COUNTY-AGENCPSTATEN NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS NOTIFICATION AND BILLING: I. ❑ It ILL❑ <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL <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&SIGNATURE) <br /> LOCAL AGENCY USE ONLY p of TANKS at SITE <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# <br /> � E= <br /> APPROVED BY NAME <br /> PHONE p WITH AREA CODE <br /> CURRENT LOCAL AGENCYFACILITYID 5a <br /> PERMIT NUMBER <br /> ' PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> BUSINESS PLAN FILED D T IL i C <br /> SUPERVISOR-DISTRICT CODE NO I 1 V./'� <br /> LOCATION CODE CENSUS�JTR2ACT#�]l ' YES <br /> 0--s- VvRECEIPT# BY: <br /> CHEGKp PERMIT AMOUNT <br /> SURCHARGE AMOUNT FEE CODE <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1 0R MORE TANK PERMIT FORM 'B' APPLICATION(S), UJHIS IS A CHANGE OF SITE INFORMATION C <br /> FORMA(3-2-SB) i <br /> `a* DATA PROCESSING COPY <br /> eS FORM MUST BE ACCC <br />