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4 FOF CALIFORNI WATER RESOURCES CONTROL BOARD W,�.•' fU.[K;'•;F�A <br /> UNDERGROUND STORAGE TANK PROGRAM r o <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> c <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE LOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ? • <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> 9' <br /> ADDRESS NEAREST CROSS STREET ✓Boz to indrale ❑ PARTNERSHIP STATE-AGENCY 1LV <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 13,36) Ad M'! t 6iz ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME / ` , STATCA ZIP D5 6 SITE <br /> �oR N E7�E <br /> TYPE OF BUSINESS: 0 2 DISTRIBUTOR ❑( 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ ❑ I� TRUST RESERVATION <br /> ANDS or ❑ #of TANICa J <br /> 1 GAS STATION 3 FARM OTHER r '�—" AT THIS SITE / <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 /> Gkq)q 146 W Lt C�04 Lf�'- a <br /> NIGHTS: NAME(LAST,FIRST) <br /> w^^ a PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> c.{//v a.�-r <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME` � � � � <br /> C_ry � CARE OF ADDRESS INFORMATION <br /> ` I �^ _- t <br /> MAILING or STREET ADDRE� ✓Box to indicate 13 PARTNERSHIP ElSTATE-AGENCY <br /> 11 CORPORATION LOCAL-AGENCY FEDERAL-AGENCY <br /> [ 0 ( ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> S C�Ph ez. . � C g <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> [7 <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: I. ❑ if. ❑ 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 /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [ [0W_ jlf? ll0i:/ 1 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Co r <br /> f <br /> PERMIT NITIABER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CENSUSTRACT SUPERVISOR-DISTRICT CODE BUSINESS FILED NO ❑ DATE FILE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> t� DATA PROCESSING COPY <br />