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STATE OF CALIFORNO WATER RESOURCES CONTR&BOARD " <br /> FORM IA,; <br /> UNDERGROUND STORAGE TANK PROGRAM = ' wl <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ) cc <br /> cc <br /> cc <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> r- 44ck . crx To � ate V6— <br /> ADDRESS NEAREST CROSS STREET ✓Bm 10 income ❑ PMTNErMIP ❑ STATE AGENCY <br /> c ❑ CNPMTON ❑ LOCAL ADBICY ❑ FEDERAL APENCY <br /> J LZ n 0 VN S SIL Cl INDIVIDUAL ❑ COUnAGENa <br /> CITY NAMF��.� STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> J1 C CA l.l1l �L <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID k <br /> RESERVATION or N of TANK'F <br /> ❑ I GASSTATION ❑ 3 FARM GTRER TRUSTLANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) f PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box m indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION Cl LOCAL-AGENCY Cl FEOERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 4an � F R � !Cc <br /> MAILING or REET//A��DDRESS ✓So.la,,oicale Cl PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATC-,7 — ❑ NDIVIDUALION D LOCAL-AGENCY❑ COUNTY-AGENCY <br /> Cl FEDERAL-AGENCY <br /> CITY NAME STAT I ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'$NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION M AGENCY N FACILITY ID M a of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE F WITH AREA CODE <br /> p c� \ -x--I <br /> PERMITNUMBER PERMIT APPROVAL DATE EPEIRTION DATE <br /> LOCATION CODE CENSUS TRT N SUPERVISOR-DISTRICT CODE N F❑ILEO ❑ DATE FILED1.4Q_CD NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> T IS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> M A(3-2-88) Y <br /> DATA PROCESSING COPY , <br /> lb ,O L <br />