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STATE OF CALIFORNI0 WATER RESOURCES CONTROBOARD <br /> FORMW: W <br /> UNDERGROUND STORAGE TANK PROGRAM �' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } � o <br /> COMPLETE THIS FORM FOR EACH AGILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMITrj 5 CHANGE OF INFORMATION <br /> ONE ITEM 7 PERMANENTLY CLOSED SITE <br /> 2 INTERIM PERMIT � 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> J 04 OV t2 <br /> ADDRESS �f �C /��y/� NEAREST CROSS STREET k//BIN to ir4iule D PMTNEBS4IP D STATE AGENCY <br /> `G I '�- • F'Y IN Cl ICOAPDIIALION D ry ENCY D FEDEAALAGENLY <br /> CITY NAME AE <br /> _ i N STAIP CODE SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA TiID N <br /> 1 GAS STATION 3 FARM ❑ 5 OTHER RESERVATION o ❑ N of TANK's <br /> I THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) TRUST LANDSEMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(I-AST,FIRST( <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate D PARTNERSHIP <br /> ❑ CORPORATION0 STATE-AGENCY <br /> D LOCAL-AGENCY D FEDERALAGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> STATE ZIP CODE <br /> PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP Cl STATEAGENCYD CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> El INDIVIDUAL COUNTY-AGENCY <br /> CITY NAME D STATE ZIP CODE PHONE p,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. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY S JURISDICTION M AGENCY N FACILITY ID k N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE �C-E7NSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED nn <br /> <j.� 'Z YES NO <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT -p <br /> as <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 /> A"d a -� � � <br />