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STATE OF CALIFORNI* WATER RESOURCES CONTROrbOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 5-1 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ T NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ove;Q - IS 7c <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ,^r e <br /> F1ADDRESS NEAREST CROSS STREET ✓Bmb MNaV PAIiiNEIBlIP El STATE <br /> 1 — FI s T ❑ OGBPORATION ❑ LOCAL Aui CY El DML FEOAGEIV <br /> Ni ❑ CLIINIV.AGENGY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> esc-ALOK) CA 53 <br /> TYPE OF BUSINESS2 DISTRIBUTOR 4 PROCESSOR v'Box if INDIAN EPA 10 N F Pf TANICS <br /> F—] 1 GAS STATION 3 FARM <br /> ❑ ❑ 5 OTHER RESERVLA ION or❑ AT THIS SITE <br /> ❑ ❑ <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 /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN 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 /> MAILING or STREET ADDRESS ✓Box 10 indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRBBS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 /> COUNTY* JURISDICTION N AGENCYA, FACILITY IDR R of TANKS at SITE " <br /> 3 [� I I I 1 :01— <br /> CURRENT <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE R WITH AREA CODE <br /> wig+ <br /> PERMIT NUEinFINUT <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION ENSUS TRACT N SUPERVISOR-DISTINCT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO ) <br /> CHECK R AMOUNTv SURCHARGE AMOUNT FEE CODE RECEIPT• B <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 /> FORM A(3-2-A&) \\ <br />