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STATE OF CALIFORA WATER RESOURCES CONTROL BOARD <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE ,D FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq(,FO R-P <br /> MARK ONLY ❑ f NEW PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANE LOSED SITE OV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE if ZPAO <br /> V <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME - CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME �%� <br /> IP CODE SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR Box if INDIAN EPA ID It <br /> #of TANK's <br /> RESERVATION or <br /> 1 GAS STATION ❑ 3 FARM El OTHER TRUST LANDS ❑ AT THIS SITE <br /> E] <br /> EMERGENCY CONTACT PERSON(PRIMARY) I 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 It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. 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 Cl FEDERAL-AGENCY <br /> ❑ 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 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#,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 /> COUNTY# JURISDICTION# AGENCY# FACT # #of TANKS at SITE <br /> F7I I Lj I a 3 —01 <br /> CURRENT LOCAL AGENCY FACILITY ID# PPROVED BY NAME PHONE#WITH AREA CODE <br /> 1 <br /> LERN RM E PERMIT EXPIRATION DATE <br /> 1F ED <br /> CENSUS TRACT 8 SUPERVISORMCT CODE BUSINESS PLAN FILED DATE rA\ 3YESNO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> "J THIS FORM MUST BE ACCOMPANIED BY AT LEAST 1) ORE TANK PERMIT FORM `B'APPLICATION(S), UNLES IS IS A CHANGE OF SITE INFORMAT4ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />