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STATE OF CALIFORNIH WATER RESOURCES CONTRPBOARD <br /> x w_ <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAMro <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C?' `` y <br /> -" COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE�O).SLT£-T I <br /> ONE ITEM [:] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE / <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME . l CARE OF ADDRESS INFORMATION <br /> rv1 0 <br /> ADDRESS /9 /NEAREST <br /> �CROSS <br /> nSTREET El✓Nox wudirate Cl EARTNERSHIP ❑ STATE AGENCY <br /> Ic I C�K !//,°/Y ❑ NDIVPORATION El ISMAL ❑ COUNTY AGE C LAGINCY ❑ FEGER4.AGENLY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N S M of TANK's <br /> ESETION <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS dr ❑ 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 N WITH AREA CODE <br /> NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N 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 indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARL OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYAT JURISDICTION P AGENCY N FACILITY ID N N of TANKS a1 SITE <br /> CURRENT LOCAL ADFACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE <br /> EN Y <br /> �o L� � C4 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECKO <br /> N CODE CENSUS TRACT M SUPERVISOR <br /> --DISTRI T CODE BUSINESS PLAN FILED DATE FILED <br /> D I �P %Z � _ YES N0 <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> 1r <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 ON <br /> FORM A(3-2.68) / <br /> / 04 04" q v DATA PROCESSING COPY C�i .v <br />