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STATE OF CALIFORNIA • WATER RESOURCES CONTROL BOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l <br /> s� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1:1 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) V <br /> N <br /> FACILITY/SITE NAME TARE OF ADDRESS INFORMATION <br /> � u <br /> ADDRESS PRIEST CROSS STREET ✓Box to intlw'ale 0 PARTNERSHIP 0 STATE AGENCY <br /> ° NTDUALIGN 0OUNYn NFEDERAL AG ry DW oINDIVIDUAL CTea <br /> CITY NAMEt LATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> J CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ESEVATION or❑ 1 GASSTATION [:] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ #af TANKS <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#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 indlcale 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE !ZIP CE PHONE#,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 ❑ PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <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. ❑ it. ❑ 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# AGENCY# FACILITY ID#. #of TANKS at SITE <br /> 5 <br /> CURRENT LOCAL AGENCY FA ILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F ED <br /> 23, 3 YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEA;JOR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) \ <br /> DATA PROCESSING COPY ��\ <br />