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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM PA': UNDERGROUND STORAGE TANK PROGRAM ! �\o <br /> SITE (TP FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION $ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMA EDSITE IV <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE � <br /> GTt <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) co <br /> FACILI /SITE NAME CARE OF AD KESS INFORMATION <br /> A <br /> ADD S_ ,^ NEAREST CR STREET ✓BOM IDiMicale ❑ LOCAL GEN 0 STATEA.AGEN <br /> S W y '/K� O RAiIGN ❑ IOUNT(ANLY 0 fEOEMLAGENCY <br /> NDNIDIIAL ❑ COUNiKAGENCY <br /> CITU NAMESTATCA P C O SITE PHONE p,WITH AREA CODE <br /> &0,0i' n/ <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESE❑ It of TANK's <br /> 1 GASSTATION �3 FARM ❑ 5 OTHER TRUSTYLANDS�r ❑ lij AT THIS SITE I <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DYq NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NA (LAST,FIRST) PHO Ex0 WITH AREA CODE <br /> Ka �J(/ <br /> NIGHTS'. NAME( ST,FIRST) PHONE#WITH AREA CODE NIGHTS. JA E(LAST,FIRST) PHOy WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) J( <br /> NAME CARE OF ADDRESS INFORMATION <br /> III <br /> MAILING or STREET ADDRESS ✓Box to,ftcate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> A <br /> MAILING or STREET ADDRESS ✓Box P,ndicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION ❑ LOCALAGENCY0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL ❑ 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. 4;12it. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> b 1 Y_ IKOT Id b <br /> CURRENTiO(1G�Y FACIL�ID M APPR ZBY NAME Q PHONE#WITH AREA CODE <br /> ; S / 5 <br /> PERMIT NUMBER PERMIT APPROVAL DATE P MIT EXIIIIAATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED D/ATE FILED <br /> 22. 2-6 YES NO !�/� Z, <br /> CHE # 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 ONL <br /> 1\ FORMA(3-2-88) <br /> DATA PROCESSING COPY � <br />