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WATER RESOURCES CONTROL BOARD <br /> .. UXDERIIGROWIM STORAGE TANK PROGRAM <br /> FACILIMSITE, INFO. rATI ION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEC? ❑2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ' <br /> 1. FACILITY/SITE IM ORi'CATION 0 ADDRESS—(MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Boz to rd= ❑ PARThERSF P ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGEI CY ❑ FfCE 1N.-AGD0 <br /> ❑ N UMOUAL ❑ =NTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # #of HIS SI <br /> ❑ 1 GAS STATION ❑3 FARM ANDIVS <br /> E 5'OTRER TRUST LANDS ATION or ❑ AT THIS SITE <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 OMER INFORi ATION A ADDRESS— (iiUST 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 /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> 111. T AML OVJMER Ii1FORMATION &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 ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL XOTIFICATION AMD BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING VrICH AC,OV13 AD22300 SHOULD BE USED FOR DOTH LEGAL NOTIFICATION AND BILLING: L ❑ II.r 0'r.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 WdLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> m I I L I I <br /> 1 , <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERIMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> i <br /> I <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO <br /> CHECK# PER941T AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOL:PANOED BY AT LEAST(t)OR MORE TANK PERMT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> =� FILE COPY <br />