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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '` +�:'"F <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM (%€ �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `+<,Foax�N <br /> MARK ON10 <br /> LY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE r <br /> ONE ITEM ❑ Z INTERIM PERMIT ❑ q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE a ' <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓I1mbiAote 0 PMTWMIP ❑ STATE.AGEWY <br /> 0 COROMTDN 0 IGCAL,IGDMN 0 FEDS L-AGBILY <br /> 0 INDMIDAL ❑ COUNIY-AGDXY tl <br /> CITY NAME STATE ZIP CODE TE PH NE#.WITH AREA CODE <br /> iqgq <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR #PROCESSOR ✓BOX#INDIAN EPA CA — <br /> ❑ I GAS STATION ❑3 FARM ❑5 OTHER TRUST LANDS or ❑ #of TANSY <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME, CARE OF ADDRESS INFORMATION <br /> � <br /> MAILING m STAEET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> N ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITU NAMESTATE ZIP CODE PHONE#,VITH AREA CODE <br /> V�2 <br /> III. TANK OWNER INFORMATION 81 ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING m STREET ADDRESS ( ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> poBOXI��z eL 0 CORPORATION ❑ LOCAL-AGENCY 11FEDERAL-AGENCY <br /> 1 C..-1 0 INDIVIDUAL 0 COUNTY-AGENCY <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. ❑ 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 B SIGNATURE) - DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> I 5 , I I I 10 <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE#WITH AREA CODE <br /> 7D T <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSUSTRACT,# SUPERVISORA�ICT CODE BUSINESS PLAN FILED; YES NO ❑ DATE <br /> CHECKN PERMIT AMOUNT SURCHARGE AYOUNT FEE CODE RECEIPTN BY: pp <br /> Ll <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-BS) <br /> \ � ) _Q low DATA PROCESSING COPY 1; <br /> 3,-(01 --- — __^ - <br />