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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD `yE"E�-K T�' <br /> �'�N <br /> P \s� <br /> FORMW: oI <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> -0 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION . ! <br /> r1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS D SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE av <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) o <br /> FACILITY/SITE NAME _t�, CARE OF ADDRESS INFORMATION <br /> / <br /> LAucS <br /> ADDRESS NEAREST CROSS STREET ✓Boz to indicate ❑ PARTNERSHIP ❑ <br /> STATE-AGENCY <br /> � ION1:1 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> N N � � DN ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID 4 If of TANK's <br /> E] 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUSTYATION ANDS or ❑ AT THIS SITE Q <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE At WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODENIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> 5? z--3 -3 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME T CARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILING or STREET ADDRESS ✓Box to in to ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ` ❑ C RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> P_ U DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY <br /> NAME__ STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> p _ <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 4,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: 1. 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> olol I 3 EEO or) <br /> CURRENT LOCAL <br /> / IvAGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> LLT <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE [RECEIPT# BY: 4 <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 /> FORMA(3-2-88) <br /> 0 DATA PROCESSING COPY 0 S <br />