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y • <br /> NATE OF CALIFORNO WATER RESOURCES CONTR CARD <br /> jU.�F 4 <br /> FORMW: <br /> : <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION/a7 , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 N ERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENT Y CLOSED SITE <br /> ONE ITEM INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> k��,/--t _r - <br /> 1 <br /> ADDRESS NEAREST CROSS STREET ✓84 reale ❑ P0.ATN€RSNIP ❑ STATE-AGENCY <br /> RPOAATION ❑ LOCAL AGENCY ❑ FENERAL AGENCY <br /> ❑ ING6WDl1aL ❑ C017N1Y-AGENCY <br /> STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CITY NAME <br /> CA <br /> EPA ID # <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR RE Box <br /> x if INDIAN <br /> or 111 <br /> FAT <br /> f TANK's <br /> 1 GAS STATION 3 FARM Q 5 OTHER TRUST LANDS TH15 517E <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �NAME(LA � o� <br /> NIGHTS: ST) <br /> PHONE#WITH AREA CODE NIGHTS. NAME{LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAI or STREET ADDRESS ✓ o indicate ElSTATE-AGENCY <br /> PARTNERSHIP ❑ <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> U ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OFADDRESS INFORMATION <br /> f / /�/• ' �INDIVIDUAL <br /> PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ATION ❑ LOCAL-AGENCY Q FEDERAL-AGENCY <br /> a, ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1I B01(INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ It. 116. <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 B.SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> ,COUNTY# JURISAGENCY# FACILITY ID# #of TANKS at SITE <br /> / 10 10- <br /> CURRENT LOCAL ACBE Y FACI <br /> LITY ID APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER RMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CO E CENSUTRASUPERVISOR-D,I+ST C E BUSINESS PLAN FILED GATE FID�r <br /> �j 6 YES p NO � h� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />