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qq <br /> STATE <br /> F CALIFORNIP WATER RESOURCES CONTROL BOARD yEP�.of;... <br /> � 6V M6M� M1F <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> �O <br /> SITE FACILITY/SITE, INFORMATION /or PERMIT APPLICATION <br /> R0 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE cy(,FO RNP <br /> MARK ONLY ❑ T NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7TLY CLOSED SITE <br /> ONE ITEM 1:12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ' O <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRQS INFORMATI <br /> ADDRESS NEAREST CROSS STREET ✓8%tO fKk to ❑ PAKNE MIF ❑ STATE.AGENCY <br /> i 11COW MTION ❑ LOCAL-AGENCY ❑ fflU I-AGENCY <br /> 1� ❑ INOMM AL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA S-3 <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box f INDIAN EPA ID N <br /> RESERVATION or #of TANK s <br /> I GAS STATION 3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY 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 Cl COUNTY-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 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 /> ENBER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [El Lf-T] I I 1 1 Lolo I / 1 <br /> ENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUSTRACT# SUPERV R-DIS ICT CODE BUSINESS PLAN FILED DATE FILED <br /> tp) YES ❑ No /PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: (�( <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> CID DATA PROCESSING COPY <br />