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TAPE CALIF RN OF TN <br /> WATER RESOURCES CONTROL BOARD <br /> FORM W: 9� <br /> UNDERGROUND STORAGE TANK PROGRAM ,,.. . -o <br /> SITE FACILITY/SITE, INFORMATION 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 LOSED SITE <br /> ONE ITEM, ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Ciro <br /> I. FACILITY/SIT INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bar b indicate ❑ PARTNERSHP 11STATE-AGENCY <br /> V ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODESITE PHONE#,WITH ARS CODE <br /> CA /�® <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR �CESSOR ✓Box it IN AN EPA ID #I GASSTATION ❑3 FARM R RESERVATI Nor #of TANK's <br /> TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If 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) i <br /> NAME F <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS . ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 11COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &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 NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1 i BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ 111.❑ <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 atITE <br /> EU -m �_=_ Lj 1 112 1 T71 Lj- I <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH ARE CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES E] too [:] 1 C C <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE COQE RECEIPT# By, <br /> THIS FORM MUST BE ACCOMPANIED BY A L (f)OR MORE TANK PERMIT FORM`B'APPLICATION(S),U ESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2.88) <br /> DATA PROCESSING COPY <br />