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l _ . , <br /> STATE OF CALIFORNIA WATER RESOURCES CONTIN BOARD A <br /> FORMW: <br /> : f R1 _� <br /> UNDERGROUND STORAGE TANK PROGRAM ' "°T 0 z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ao <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE cq"`oa^w <br /> MARK ONLY ❑ I NEW PERMIT ❑, 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT CLOSED SITE <br /> ONE ITEM ❑ 2 INTEREM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> CD <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> fNEA�RfSTClRll0l:SS STREET ✓Box IDindicale Cl PARTNERSHIP ❑ STATE-AGENCY <br /> f} ❑ PORATION ❑ LOCAL-AGENCY Cl FEGFRAL AGENCY <br /> 1 ''�/ T S(JVU OIVIOUAL ❑ COUNTY-AGENCY <br /> CITY NAME NJ STATE ZIP CODE SITE PHONE Or WITH AREA CODE <br /> CA S4A D <br /> TYPE OF BUSINESS F—] 2 DISTRIBUTOR 714 PRODES50R ✓Box i1 INDIAN EPA ID # of TANK'a <br /> GAS STATION [:] 3 FARM <br /> ❑ 5 OTHER TRUSTVATION LANDS�r ❑ AT THIS SITE <br /> ID— <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYSNAME(LAST,FIRST) PHONE#WITH <br /> /AREA <br /> 7CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> / -R A <br /> NIGHTS', NAME(LAST, RST) PHONE N WITH AREACODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRES ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑�, C�RRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> LV0fN©IVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE It,WITH AREA CODE <br /> hzodli <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME y,�p CARE OF ADDRESS INFORMATION <br /> S G <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. ❑ if. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED CINDER 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# FACILITY ID# #of TANKS at SITE <br /> [ I I j F(IT01I13100 (1an �. <br /> CURRENT LOCAL AGENCYFACIL`TY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> ` <br /> PERMIT NU ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 00 X300 �A 3/[?r <br /> LOCATION CODE CEN CT M SU ERVISOR-DISTRICT CODE BUSIN $R FILED <br /> DATE FILED �` <br /> 1 3, 1{VYrr��F YES El NO ❑ I I U <br /> CHECK# 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 ON <br /> FORM A(3-2-98p <br /> DATA PROCESSING COPY <br />