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STATE OF CALIFORNIll WATER RESOURCES CONTRABOARD <br /> UNDERGROUND STORAGE TANK PROGRAM ;' o <br /> SITE VACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> z <br /> COMPLETE THIS FORM FOR EACH FAC LITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMAN T C E ITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ❑ � —1 <br /> 1. FACILITY/SITE INFORMATION & ADDRI'ESS�SQn— (MUS,T' BE COMPLETED) go <br /> FACILITY/SITE E N #�Lw �E -�/ CARE OA/�DDRESS INFORMATION <br /> ADDRESS N ST CROSS T ✓BoxtaiMute 15PAR7NEFSHIP ❑ STATEAGENCY <br /> / ❑ CORPOkj <br /> ❑ LOCALAGEND Cl FEDERALAGENCY <br /> ❑ INDIVID ❑ COUNTY AGENCY <br /> CITY NAME 1 STATE iL ZI C P NE q,WITH AREA CODE <br /> t CAPD 33- <br /> TYPE OF BUSINESS. ❑ 2 STRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID n <br /> ❑ I GAS STATION 3 FARM S OTHER RESERVATION or - #of TANK's <br /> ❑ TRUST LANDS ❑ PQ AT THIS SITE o <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> D YSNAME(LAST,FIRST) 1 ONE N WITH AREA CODE DAYS'. N LAST,FIRST) PHONES p ITH AREA CODE <br /> NIGHTS: NAME(LAST FI STI PHONE#. <br /> H AREA CO E NIGHTS: A E(LAST,FIRST) PHONE k/ <br /> TH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 14 <br /> MAILINGo STREET ADDRESS ✓8ox loind,rote ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <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 /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <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 BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> m I t.J o 1p o <br /> CURE T LOCAL AGENCY FACT ITV ID# APPFIPVED BY NAME IF PHONE#WITH AREA CODE <br /> W <br /> PERMIT NUMBER PERMIT APPROVAL DATE PE M T EXPI TION DATE <br /> LOCMI <br /> E CENSUS TRACT# n SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ATE FILED <br /> A Z_` Z,6 YES ❑ NO 7 f Q <br /> CNE PERMIT AMOUNT SURCHA GE AMOUNT CODE RECEIPT p BY: VVV <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />