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STATE OF CALIFORNll WATER RESOURCES CONTRO BOARD <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C4�,FORN`P <br /> J <br /> MARK ONLY,":;-, 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7)PERMANENTLY CLOSED SITE <br /> �❑ ❑ <br /> ONE ITEM, �,: / F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE. , <br /> a� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS ,NFAREST CROSS STREET ( '_ Bortoindicate ❑ PARTNERSHIP ElSTATE-AGENCY �">] <br /> • ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> C4-'A001CIDUAL ❑ COUNTY-AGENCY vrY <br /> CITY NAME STATE ZIP CODE SITE PHONE# WITH AREA CODE <br /> r <br /> ATION <br /> TYPE QF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN /� #of TANK's., <br /> 1 GAS STATION ❑ 3 FARM R TRUSTL ANDS or ❑ EPA ID ID It 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#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) /f PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#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 ❑_EEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY '-'--r <br /> CITY..NAME STATE ZIP CODE PHONE it,WITH AREA CODE <br /> l� <br /> III.,TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAMk CARE OF ADDRESS INFORMATION <br /> MAILIIJG or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIIK NAME STATE ZW CODE PHE#,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. ❑ 111. ❑ <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 /> [PERN <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> f <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR DISTRICT CODE BUSINESS PLAN FILEDD/�TE FILED <br /> YES NOPERMIT 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 /> FILE COPY <br />