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STATE OF CALIFOR40 WATER RESOURCES COI0001OARD �0`;FSF <br /> ter. `sx <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 ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER LY CLOSED SITE <br /> ONE ITEM 1:1 INTERIM PERMIT E]4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME f 7CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> &4,) /I jJ�( NEAR T CROSS STREET (/ �}� ilairOrsle ❑ FANTNLA511IP ❑ STATE-AGENCY <br /> 7"'�� "7/' ' "` Cl INDIVIDUAL D LOCAL-AGENCY <br /> WNTY AGS Y ° FR)ERAL-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHON #.W /7EA O Fj <br /> CA 1 7 <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Bo.it INDIAN EPA ID # <br /> N of TANK"s <br /> RESERVATION or <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. SAME(LAST FIRS_J) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) P 0 E N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESSx 10 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPDRATION ❑ LOCAL-AGENCY Cl 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 /> NAMECARE OF ADDRESS INFORMATION <br /> C097- (2F S 70�bf'7fJ_'' <br /> MAILING or STREET ADDRESSn, r ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> [�/ V CORPORATION [_1 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ( V 1! V V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CQDE lye <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICN 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#t JURISDICTION I# AGENCY#I FACILITY ID 8 #of TANKS at SITE <br /> b � ` 0 <br /> 1 A- <br /> CURRENT LOCAL AGENCY ACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> ri 7 :v` <br /> PERMIT NUMBER I PERMIT_APPROYAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTN PERP,/OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO � <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE TRECEIPT N 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 /> ORM A(3-2-13IB) 0 9 <br />