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STATE OF CALIFORNIV WATER RESOURCES CONTROBOARD <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION IZ o <br /> 74 COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1-J. <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE .3 r <br /> N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FAME NAME Iq CARE OF ADDRESS INFORMATION co <br /> ADDRESS A NEAREST CROSS STREETTO <br /> o irdigle RTNERSHIP D FATEAGENCY <br /> PORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> VIDUAL ❑ COUNttAGENCY <br /> CITY NAME STATE ZI CODESITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINE ❑ 2 DIS ISUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID # <br /> F-1ESE1 GASSTATION 3 FARM ❑ 5 OTHER TRUSTVATION LANDS o ❑ #of TANK'a / <br /> AT TRIS SITE <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#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME �)a g�z CARE OF ADDRESS INFORMATION <br /> L\J <br /> MAILING or STREET ADDRESS ✓Dox tolntlicale D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNT)(AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER FORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Dox 1oln0icale D PARTNERSHIP D STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERALAGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> = I I IZ/ � .� <br /> CURREN OCAL AGENCY FACILITY 10# APPROVED BY NAME <br /> nz)6 r� / PHONE M WITH AREA CODE <br /> PERMIT NUMBER L� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA�TyIj��+CODE CENSUS TRACT# SUP3ERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE YES ❑RECEIPT If ❑ �,2 <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 /> le DATA PROCESSING COPY • <br />