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0 <br /> STATE OF CALIFORNIAP WATER RESOURCES CONTROL ARD . " " r`SA <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 e` <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANNEE TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ISO .+ <br /> J <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ENCY <br /> ADDRESS HE REST CROSS STREET D CORPORATION 1:1LOGAII�AGENCY D EEOEHALRSHIP 0 STATE O-AGENCY <br /> (� D INDIVIDUAL D crouunA a" <br /> CITU NAME STATE ZIP CODE ITE PHO p.WITH AREA CODE <br /> CA S(y <br /> TYPE OF BUSINESS'. 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID 4 N of TANK'8 <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DIA}YS. NAME(LAST.FIRST) <br /> PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> J I a L--' Cao J l� PHONE p WITH AREA CODE <br /> NIGHTS. NAME( ST,FIRST) PHONE p WITH AREA CODE NIGHTS'. NAME(LAST FIRST) <br /> S aA--e- <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME L <br /> MAILING or STREET ADDS ✓Doxiaintlicale Cl PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL-AGENGV Cl FEDERALAGENCY <br /> ❑ INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> C o 1 ld 3 <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Dox to ir14icato D PARTNERSHIP D STATEAGENCY <br /> ❑ CORPORATION D LOCALAGENCYD FEDERALAGENCY <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. ❑ II. III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE, 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 /> 0O I 7 U © O <br /> ff2RMIT <br /> Y FACILITY ID p <br /> APPRO D E PHONE p WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT E%PIRATION DATE <br /> NSUS TRAC � SUPERVISORTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3YES NO �CRMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p B <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST I R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \ <br /> 1 ORM A(3-2-88) \1 \ <br /> DATA PROCESSING COPY (� <br /> � '`1L <br />