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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMW: UNDERGROUND STORAGE TANK PROGRAM <br /> �,� �. <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� 4 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 10s CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE R <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE 5 c <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> FA W/SITE NAME CARE OF ADDRESS INFORMATION <br /> G <br /> ADDRESS n <br /> IFAQIST CROSS STREET ✓Bm 0ill6,aa 0 PAITTNEIIEK? 0 STATE AGENCY <br /> (� 0 COWWMN 0 LDGL <br /> ,� -AGENCY 0 FEDER44AGENIX <br /> S { )/j/ L 0 INDMWAL Cl COUNTY AGENCY <br /> CITY NAME STATECOD ITE PHONE#,WITH AREA CODE <br /> CA 33(vao — <br /> TYPE 0 BUSINESS: ❑2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID n #of TANK's <br /> RESERVATION or ❑ AT THIS SITE <br /> 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTLANDS <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 It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & DDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- ( ST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP C STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME TATE 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 LE L NOTIFICATION AND BILLING: I. ❑ it. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO T 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# If of TANKS at SITE <br /> CURRENT L AL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> � a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK <br /> DE CENSUS�jTRACT SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DA/TE-FILED Q <br /> � 3 ' 3 YES NO � <br /> PERMIT AMOUNT II// SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)0 MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br /> n <br />