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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM =` a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑q AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> V <br /> ADDRESS NEAREST CROSS STREET ✓ Amara 0 PA3INEWR ❑ KAMAGENCY N <br /> 2 e. POMTION ❑ LOCAL-AGENCY ❑ FEOEMIAGINY <br /> I L.50 iNDMDuu ❑ CWMAGFNCY ly <br /> CITU NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> N CA 11899 -Mg I I <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑d PROCESSOR ✓Box if INDIAN EPA ID n <br /> ❑ I GAS3TATION ❑3 FARMF—W5 OTHER RESERVATION <br /> ION or ❑ M of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE K WITH AREA CODE DAYS'. NAME(LASTFlRST) PHONE K WITH AREA CODE <br /> NIGHTS: NAME(LAS ,FIRST) PHONE It WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE K WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Yii PIS em-FF- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 15 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <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 CAREOF DRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ `o indicate 13 El <br /> El STATE-AGENCY <br /> � RPORATION ElLOCAL-AGENCY 13FEDERAL-AGENCY <br /> LI INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE I PHONE It,WITH AREA CODE <br /> A blD <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. ❑ IL ❑ 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 M JURISDICTION k AGENCY# FACILITY ID If #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-014 <br /> UPERVISOR-DI TRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES E] NO <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 0 Y. <br /> 1 FORM A 13-2-88) <br /> �/ a. DATA PROCESSING COPY <br />