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STATE OF CALIFORNIA WATER RESOURCESCON_UWlrSO4CRD : <br /> FORMA': <br /> " ' <br /> UNDERGROUND STORAGE TANK PROGRAM =� o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SITE ri <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 5t 7a. <br /> to <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) t0 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> S sir r ' <br /> ADDRESS NEAR ST -/Box to Mule 11 PARTNERSHIP ElSTATEAGENCY <br /> "-0 opw ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ❑ COUNIYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CA 5 a Jr ? .3� _ �� <br /> TYPE OF BUSINESS'. 2 DISTRIBUTOR ❑ 4 P OCESSOR ✓Box it INDIAN EPA ID k <br /> RESERVATION or #of TANK's <br /> ❑ 1 GASSTATION ❑ 3 FARM OTHER TRUST LANDS 1:1 AT THIS SITE <br /> EMERGENCY CONTACT PERSON PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(EAST FIRST) PHONE WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE H WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATIO &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#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 ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR II LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> = = = 10O <br /> CURRENT LOCAL AGENCY FACILITY ID At APPROVED BY NAME PHONE#WITH AREA CODE <br /> 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATELFEE <br /> PERMIT EXPIRATION DATE <br /> L <br /> CODE CENSUS TRACT# SUPERVISO O�TR� BUSINESS PLAN FILED ❑ DATE FILED �C <br /> 3 YES NO Q <br /> t <br /> PERMIT AMOUNT SURCHARGE AMOUNTODE RECEIPT# BY: <br /> /I THIS FORM MUST BE ACCOMPANIED BY AT LEAST f MORE TANK PERMIT FORM 'B'APPLICATION(S), U8 THIS IS A CHANGE OF SITE INFORMATION ONLY. v <br /> / FORM A(3-2-88) � <br /> (� <br /> DATA PROCESSING COPY `� <br />