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STATE OF CALIFORNtX WATER RESOURCES CONTReBOARD a <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEWrMMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION El PERMANENTLY CLOSED SITE }-► <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> f✓ <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) Ln <br /> FACILITY/SITE NAME _ <br /> _ �yCARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓BmwM 0 PARTNERSHIP 0 STATE AGENLT <br /> �'� - l✓ 0 COVORATION 0 LOCAL ACERGY 0 PEGEW AGENCY <br /> 0 Nmwk ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR i% d PROCESSOR ✓Box if INDIAN EPA ID p <br /> RESERVATION N M of HIS SI <br /> ❑ i GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING n STREET ADDRESS ✓Boa I.Ind¢.[. 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 1.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATIONi <br /> MAILING or STREET ADDRESS ✓Box to indica[. 0 PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p.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: L ❑ 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 B JURISDICTION M AGENCY B FACILITY ID A Al of TANKS at SITE <br /> m <br /> CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAME PHONE Y WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FI D <br /> YES NO [] Z3 <br /> CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y 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 /> FORM A(\3-2-88) r7 �yL7/,a <br /> DATA PROCESSING COPY <br />