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STATE OF CALIFORNS WATER RESOURCES CONT BOARD <br /> FORMA`: UNDERGROUND STORAGE TANK PROGRAM =� o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 'o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION PEso RMANENTLY CLOSED SITE N <br /> ❑ <br /> W <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �V <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 00 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Boxlpom 0 PARTNERLm-A EN 0 STATE AGENCY <br /> FMmLAGEN <br /> LA 1�� rye 0 CONPONATION 0 LOCAL-AGENCY ❑ FE➢EMI-AGFNC! <br /> 1 , ,@­l.Il ❑ INOINWAL ❑ COUNTY-AGENCI <br /> CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE <br /> S+vlv-x CA <br /> TYPE OF BUSINESS: ❑ p DISTRIBUIOfl E] -/Box if INDIAN EPA ID M 4 PROCESSOR RESERVATION or #of TANK'a <br /> ❑ I <br /> ❑ I GASSTATION ❑3 FARM <br /> 5 OTHER TRUST LANDS ElAT THIS SITE v <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) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Be.to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If.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. ❑ Ill. ❑ <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 S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> 3 qb too <br /> CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE <br /> -TANSm4l <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DIST CT CODE BUSINESS PUN FILED DATE FILED <br /> a a YES E <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t MORE TANK PERMIT FORM 'B'APPLICATION(S), LINL HIS IS A CHANGE OF SITE INFORMATION ONLY <br /> RM A(3-2-88) <br /> DATA PROCESSING COPY <br />