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STATE OF CALI FO P 4IA WATER RESOURCES CON ROL BOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� i <br /> w.. COMPLETE THIS FORM FOR EACH FACILITY/SITE '��IfpRN <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN TLY LO D SITE <br />°I ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> FACT <br /> CARE OF 4DPRESS INFORMATION <br /> Cj <br /> ADDRESS /1 Z NEA ST CROSS STREET 4 ✓Box b id TIO ❑ PARTWASIO ❑ STATE-/GENLY <br /> ❑ l�+ma+AnoN ❑ Loca ACENcrK--� <br /> Eltava;AL ❑ courrn-AMCY <br /> CITY NAME STATE ZIP ODE SITE PHO E WITH AREA CODE <br /> E- 1� / CA Z`> 2� <br /> Wl <br /> USINESS: ❑2 DISTRIBUTOR ❑/PROCESSOR ✓Box it INDIAN EPA IDN A o1 TANK'RRESE /� <br /> S STATION ❑3 FARM ❑5 OTHER TRUST LANDS« ❑ AT THIS SITE (/ <br />:y <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> ~ DAYS: E(LAST,FIRST - PHONE N WITH AREA CODE VS: N E(LAST,FIRST) P NE N WITH AREA CODE <br /> A 51A <br /> f7 NEN WITH AREA CODE <br /> NIGHTS: NAME IF,FIRST) PHOJE N WITH AREA CODE NIGHTS: ME(LAST,FIRST) <br />,w <br /> y` 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME i— CARE OF ADDRESS INFORMATION <br /> MAILt G or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> I"r <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> ..r <br /> NAME ,!;_ CARE OF ADDRESS INFORMATION <br /> sm <br /> MA ING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> .r ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. II. ❑ 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 /> FCHECK# <br /> JURISDICTION N AGENCY M FACILITY ID N X o1 TANKS at SITE <br /> ._. <br /> LOCAL FACILITY IDN APP OVED BY NAM PHONE R WITH AREA CODE <br /> y 33 PERMIT APPROVAL DATE PERMIT I( IRATION DATE <br /> CENSUS TRACT R SUPERVISOR-DISTRICT CODE 8U81NE88 PLAN FILED ATE FILED <br /> '7 IFO YES F] NO G � ?l <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT R BY: <br /> TNIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE TANK PERMIT FORM'BI APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2.88) <br /> 1 ..J DATA PROCESSING COPY L , <br />