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STATE OF CALIFORNIV WATER RESOURCES CONTROLBOARD <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Er5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT E] 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CA) <br /> LIT//$LTE CARE OF ADDRESS INFORMATION <br /> ADDRESS ,^ 7 NEAREST CROSS STREET ✓ xlo iMirale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> L S �(/J/ NPORATION ❑ LOCAL ❑ FEDERAL AGENCY <br /> J ❑ INGIVIGUAI ❑ COUNT(AGENCY <br /> CITY NA STATE ZIP CODE / SITE PHONE#,WITH AREA CODE <br /> CA y <br /> TYPE OF BI- INESS: [L:] p D TRIBUTOP ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> RESERVATION or #of TANK's <br /> ❑ I GAS STATION [313 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY 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 ❑ 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 ADDR S ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOfAL/10E,NCY FA%L17YJQ N APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER/J'_`!`J C`- //O`/(//J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> ODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE RED <br /> �j�.� �-- YES NO ❑ 6 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: o <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 R`MATION ONLY. <br /> FORMA(3-2-88) <br /> • DATA PROCESSING COPY <br />