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r.., ,:_ .n._ 1,. - .o-...♦. m. m?�T'�^^^"-+QTS`,+'1lY"w.-.-� <br /> STATE OF CALIFORNIP WATER RESOURCES CONTRBOARD '. <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM � <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION e a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION %7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ P INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CO <br /> CD <br /> FACILI /SITE NAME L• CA WDOyATION <br /> UO <br /> ADDRESS NEAREST CROSS STREET <br /> ✓Bw lD Mule ❑ PARTNERSHIP ❑ STATE AGENLY <br /> ❑ CORPMATION 11LOCALAGENCY ❑ FEOERALAGENM <br /> ❑ INDIVIDUAL ❑ COUNGAGENCY <br /> CITY NAS STATE ZIP CODE TE PH E#,WITH AREA CODE <br /> CA Cl 0=1 <br /> TYPE OF Bu5wE35: ❑ 201STRIBUTDR ❑ 4P'0CESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ❑ 1 GAS STATION UC] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE Q <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 I <br /> p CARE OF ADDRESS INFORMATION <br /> MAILING ar STREET ADDRESS ✓80x fo md,cale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING.,STREET ADDRESS I/Box lo,,,bcale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ 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. ❑ 1U ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> MI = = 1 1 141o -i3- 0 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> a3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED QDATI FILE <br /> a3.a3 a cp <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> T FORM M�T BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.^ <br /> DATA PROCESSING COPY <br />