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STATE OF CALIFORNI.0 WATER RESOURCES CONTRORIOARD <br /> FORMW: _ <br /> UNDERGROUND STORAGE TANK PROGRAM �a tlWm <br /> SITE i/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH!" <br /> F ILITY/SITE �"='FOP_ 1 <br /> FMARK,ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7PE LY�EEFS" CTEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> U's <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) OD <br /> FACILITY/SITE NAME. CARE OF ADDRESS INFORMATION <br /> (-,C.- egl fA A57 <br /> ADDRESS ,./ \ ! NEAREST CROSS STREET ✓B.Ibmale 0 PARTNERSHIP 0 STATEAGENCY <br /> 1 C/fj , I ® �D �, - e}� 1 e 0 CORPORATION 0 LOCAL AGENCY ❑ FEDERAL AGENCY <br /> C/ �`�V Cl IND OVAL 0 COUNTY AGENCY <br /> CITY NAME L G,�p STATE 21P CODE SITE PHONE JI.WITHAREA CODE <br /> f" <br /> CAI q553_6 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID x <br /> ESE❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUSTVLANDS ATION of ❑ AT If ofTHIS SITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> H. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to in6icale ❑ PARTNERSHIP D STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to ind,cele D PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE N.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. ❑ it. ❑ 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 S JURISDICTION B AGENCY M FACILITY ID If Ar of TANKS AL SITE <br /> CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> �l L,IL,6-10 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT At SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 93 / YES NO <br /> CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y BY:/w <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ` FORM A(3-2-88) <br /> �G� 0 DATA PROCESSING COPY <br />