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STATE OF CALIFORNIR WATER RESOURCES CONTROL BOARD <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> A COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT Eg-, CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (_.l G <br /> G <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY-!v/SITE NAME CARE OF ADDRESS INFORMATION <br /> r <br /> Ez� Au <br /> ADDRESS NEAREST CROSS STREET I/Box to 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL- <br /> AGENCY <br /> )- Vf= L ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> L' CA = ) <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR I❑ 4 PROCESSOR ✓Box II INDIAN EPA IDRESEa <br /> ❑ ❑ Lam° TRUSTLANDSATION ❑ AT THIS SITE <br /> I GAS STATION 3 FARM OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST( PHONE it WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#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 /> 7 <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ft,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box tolndicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE it 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. ❑ 111. ❑ <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 /> COUNTYLI JURISDICTION# AGENCY# FACILITYIDLII_ #of TANKS at SITE <br /> Ell <br /> CURRENT LOCAL AGENCY FACILITY IDM ^' - ` APPROVED BY NAM // 3. / PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMI APPROVAL DATE PERMIT EXPIRATION)DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> h <br /> THIS FORM MUST BE ACCOMPANIED BXA�LEAST I R MORE TANK PERMIT FORM `B'APPLICATION(S), UNL SS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> DATA PROCESSING COPY <br />