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STATE OF CALIFORNIA * WATER RESOURCES CONTROL JOIRD <br /> UNDERGROUND STORAGE TANK PROGRAM _ a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Q -� <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IVCHANGE OF INFORMATION ❑ 7 PER LO ED SITE Z <br /> •Q <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CCARE OF ADDRESS INFORMATION <br /> ADDRESS ) NEAREST CROSS STREET ✓Hux rtule 1:1 PARTNERSHIP D STATEAGENCY <br /> D C <br /> 2/ S� ((/S I DORATDN D LOUALAGENCY ❑ FEDERAL AGENCY <br /> D OM6'IOUAL D COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE / SITE PHONE N,WITH AREA CODE <br /> CA � ; ? 6 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 1 PROCESSOR ✓Box if INDI N EPA ID p M of TANMs <br /> RESERVATION or <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ 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#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 Cl PARTNERSHIP D STATE-AGENCY <br /> Cl CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ if. ❑ 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 k JURISDICTION k AGENCY k FACILITY ID k If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE , PERMIT EXPIRATION DATE <br /> LCHECKO <br /> E CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ( j-l) - _y YES NO /._ <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: V <br /> C2 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) V / <br /> DATA PROCESSING COPY � / <br />