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CT <br /> STATE OF CALIFORN11 WATER RESOURCES CONTROL BOARD «SEPEua.x;•r�f.. <br /> I WP: �Sa <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM W`� � "no <br /> °m <br /> Sl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C\!,PORN P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ATCHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURELED '4 <br /> F-u <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) O <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> r <br /> ADDRESS NEAR ST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> u�IJ ❑ CO�RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> /a P f✓G ' a r ILYINDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ODE SITE PHONE a,WITH AREA CODE <br /> S G q / CA (2LOD 23f 7 IO <br /> TYPE OF BUSINESS: ❑ 2 D TRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a '}-�' /� <br /> ❑ ❑ TRUSRTVLANDS ATION of ❑ �1'N Vl� A of HIS SITE <br /> 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> �o a v 3 <br /> NIGHTS: NA (LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. 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 ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME ,�s� CARE OF ADDRESS INFORMATION <br /> SO-4'V�e. 0 S Ct <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,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. ❑ Ill. ❑ <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# AGENCY# FACILITY ID# #of TANKS at SITE <br /> /! <br /> [�jy <br /> l LO0 <br /> CURRENT LOCA AGENCY FACILITY # <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F ED <br /> YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 7�013E RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />