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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> 5«a Tryf <br /> i. aunti i <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE C-I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b <br /> COMPLETE THIS FORM FOR EACH,FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P Y CLOSED SITE IJ <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE a <br /> a <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> W <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> OM <br /> �✓ VCS <br /> ADDRESS NEAREST CROSS STREETto irtiule ❑ PWNESSHF ElSTATE AGENCY <br /> iJ Qv C/JRPGRINGN ❑ LOCk AGEN:Y ❑ FEDBALAGENCY <br /> Cl INDmouu ❑ C0JNTYAGENCY <br /> CITY NAME STK/✓ STATE ZIPWDE_�v SITE PHONE p,WITH AREA CODE <br /> CA SS <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ ❑ ❑ TflUSTVLANDS Nr ❑ F of TANSY <br /> 1 GAS STATION 3 FARM 5 OTHER 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 N WITH AREA CODE <br /> /Ck <br /> NIGHTS'. NAME(LAST,FRjt-) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> L( <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> fI5l� .S'/ar MATION <br /> I <br /> MAILING or STREET ADDRESS O " ✓ ox to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> kill" <br /> INDIVIDUAL ❑ COUNTYAGENCY <br /> qS�ZV <br /> CITY NAME �� STATE f ZIP CODEPHONE N.WITH AREA CODE <br /> 74 <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION I <br /> A4 L <br /> MAILING or STREET ADDRESSox to intlicale ❑ PARTNERSHIP 11STATE-AGENCY <br /> pin I Q p/ O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> V INDIVIDUAL 11COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> S � <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. ❑ II. ❑ 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 A SIGNATURE) DATE ', <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION N AGENCY R FACILITY ID# R of TANKS at SITE <br /> (� T 3 (tl- 1 01 o <br /> I CURRENT LOCAL AGENCY) ILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVIB R-DI8TRICT CODE BUSINESS PLAN FILED NO ❑ DA72j5 <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> 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 /> FORMA(3-2-88) <br /> 1paw DATA PROCESSING COPY .,� <br />