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y,F, OFSTATE OF CALIFORNIP WATER RESOURCES CONTROIL90ARD <br /> TyF <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE <br /> FACILITY/SITE, and/or ; <br /> COMPLETE THIS FORM FOR EACH1 / ITEEMARK 0 °"ciFoa�`P <br /> ONLY E] 1 NEW PERMIT 3 RENEWAL PERMIT Q�j5 CHANGE OF INFORMATION TLY CLOSED SITE <br /> ONE IT ]2 INTERIM PERMIT ® 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION —(MUST BE COMPLETED) <br /> FACILITY/SITE NAME es CARE OF ADDRES%INFORMATION • <br /> �s0A V I , <br /> ADDRESS NEAREST CROSS S EET b ndcate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 6z vr+ <br /> rCOPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> P NIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AR A CODE <br /> CA <br /> TYPE OF SINESS: ®2 DISTRIBUTOR [_ PRESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or k of TANK'a <br /> 1 GAS STATION ®3 FARM ® 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> CONTACTEMERGENCY PERSON(PRIMARY) Y CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) 1 PHON AREA CODE DAYFj NAME(LAST,FIR T) v r #WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE IfWITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I ® PROPERTY OWNER I — ) <br /> NAME ® fCARE OF ADDRESS INFORMATION <br /> lr 7 <br /> MAILING or STREET AD ESSx to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 1 �} INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ( STATE ZIP CODE PHONE#WITH AREA CODE <br /> F11 <br /> III. TANK OWNER INFORMATION ) <br /> NAME CARE OFADO SS INFORMATION <br /> MAILING or STREET ADDRESSox to indicate 11 PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION <br /> CE ONE(1)BOX INDICATING WHICH ABOVE ADDIMIN SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: 1. 11. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY-USE ONLY <br /> [PEBER JURISDICTION# AGENCY k FACILITYID# #of TANKS at SITE <br /> _j I Im [ I N <br /> CURRENT ENCY FACILITY ID k APPROVED Y PH E k WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CE US TRACT k SU RVIS -DIS I CO BUSIE N FILED TE FILEDfD YES No PERMIT AMOUNT SURCHARGE AMOUNT E CODE RECEIPT k Y: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE T ICTI O,UNLESS THIS IS A CHANGE OF SITE li�ORMATION ONLY. <br /> FORM A(3-2-88) <br /> i <br />