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�.- <br /> STATE OF CALIFORNO WATER RESOURCES CONTRO BOARDS <br /> FORMW: <br /> : UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE:THIS FORM FOR EACH FACILITY/SITE Fie='` <br /> MARK ONLY iJ 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> Id <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ell <br /> ADDRESS NEAREST CROSS STREET ✓B - kale Fl PARTNERSHIP ElSTATE-AGENCY ci-) <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> A- (:_ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> I� CA 9.S32U _I <br /> TYPE OF BU&NESS [�j p DISTRIBUTOR 4 PROCE ✓Box ii INDIAN q� EPA IDN }�� �/ #of TANK's <br /> LSEATION <br /> 1 GAS STATION ❑ 3 FARM HER TRUST LANDS or (' vw Cl- AT THIS 517E <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,FI ST) PHffNE N WITH AREA CODE NIGHTS: NAME(LAST,FAST) PH NF#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> ,� /� JJ��_� e�,_, CARE OF ADDRESS INFORMATION <br /> NAME P�i LITS ` ' V I <br /> MAILING or OREET ADDRESS ✓8 ndicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME �r STATE ZIP CODE PHONE 0,WITH AREA CODE <br /> E3�� <br /> III. TANK OWNER INF MATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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: 1. ❑ IL 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 /> v <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS of SITE <br /> LLI I oa o C C} <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �+4G(I ;:`0 i <br /> [PERMIT PERMIT APPROVAL DAT€ PE IT EXPIRATION DAT€ <br /> CENSUS RA T SUPER ISOR (STRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> P RMIT AMOUNT SUACHARG€AMOUN FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3.2-88) <br /> DATA PROCESSING COPY <br />