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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `AN: , <br /> SITE <br /> UNDERGROUND STORAGE TANK PROGRAMFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> T COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ T PERMANENTLY CLOSED SITE }a <br /> ❑4 AMENDED PERMIT ❑ fi TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) ~ <br /> FACILITY/SITE NAME <br /> CD <br /> D _ CARE OF ADDRESS INFORMATION <br /> T. <br /> ADDRESS _ <br /> �// �C NEAREST CROSS STREET ✓&p�yk ❑ p,IgtypAypp yTATE#GENLY <br /> V �7 ❑ COWWT ❑ LOCAL.AGENCY 0 EEDEPA.AGENLY <br /> CITY NAME STATE 0 ImwoW 0 COUVTYAGENCT <br /> lesC/) �/N `' ZIP CODE SITE PHONE N,WITH AREA CODE <br /> TYPE OF BUSINESS. /'��CJ,Y� CA <br /> ❑2 DISTRIBUTOR ❑d PROCESSOR ✓Box if INDIAN EPA ID N <br /> ❑ I GAS STATION ❑ 3 FARM ❑50THER RESERVATION or If of TANK's O <br /> TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGEICY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS. NAMELAST,FIRST)) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓BOX to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME 11 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,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 0 PARTNERSHIP GSTATE-AGENCY <br /> El CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCYEl INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t)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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY40 JURISDICTION N AGENCY* FACILITY ID N N of TANKS at SITE <br /> CURRENT LOCAL AGENCY ACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> f�2/ - ,Z/ <br /> PERMIT NUMBER ' PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE <br /> YES E] NO 1 S <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY; <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. _ <br /> FORM A(3-RM J <br /> DATA PROCESSING COPY '�'� <br />