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STATE OF CALIFORNAD WATER RESOURCES CONTRAOARD <br /> FORMW:: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F—] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENT ITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITENA CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bo eicale D PARTNERSHIP D STATEAGENCYN <br /> 'i D LOCAL-AGENCY D FEDERALAGENCY <br /> ❑ INDIVIDUAL D COUNTY- <br /> AGENCY <br /> CITU NAME STATE ZIPCQ�E SITE PHONE A,WITH AREA Cn <br /> TYPE OF BUSINESS: ❑ 2 DISTRISUTOR ❑ 4 PRO' R ✓Rox if INDIAN FPA IDN y5 - #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM THER TRUSTTRESERVATION LANDS G ❑ AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> F <br /> : NA E(LAST FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> TS: NA (LAST. IHST) - HONE#WITH AREA CODE NIGHTS: NAME(LA FIR T) PHONE q WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME Aeohleli <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓B oindicate D PARTNERSHIP D STATE-AGENCY <br /> ORPORATION D LOCALAGENCYD FEDERAL-AGENCY <br /> CIDe% D INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME, � /FISTATE ZIPCODE PHONE P.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 D PARTNERSHIP D STATEAGENCY <br /> D CORPORATION D LOCALAGENCYD FEDERALAGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE q,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. ❑ I. 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# FACILITY ID At #of TANKS BI SITE <br /> CURRENT LOCAI.AGENCY FACILITYID# I APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE ]� PERMITEXPIRATION DATE <br /> N <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESYPELSNF❑ILEO NO <br /> DATEFIIsEQ/� � <br /> O(/ <br /> in <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> \ THIS 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 /> FORM A(3-2-88) • <br /> DATA PROCESSING COPY <br />