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STATE OF CALIFORNIr WATER RESOURCES CONTROL <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM " "" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION t == <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED E kV <br /> ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> W <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) w <br /> FACILI /SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bu Ioimicate D PARTNERSHIP D STATE AGENCY <br /> 41, <br /> ❑ CORONATION D LOCAL AGENCY D FEDERAL AGENCY <br /> ❑ INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> 13 CA 5 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IDRESEp N of TANK's <br /> ATION <br /> .+ <br /> ❑ I GAS STATION ❑ 3 FARM OTHER TRUSTYLANUSo ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSO (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(IAST,FIRST) PHONE k WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE 9 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMA ON & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box Io indicate D PARTNERSHIP ❑ STATEAGENCY <br /> D CORPORATION D LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE b,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADD ESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCALAGENCY ❑ 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 ADDR SS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD E USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFERJURY,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 N JURISDICTION N AGENCY N FACILITY ID# #of TANKS BI SITE <br /> a 100 ,E a I I 1 1-61 <br /> CURRENTAL AGENCY ACILITY ID MOL— APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CES TRACT SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED NO <br /> ❑ DATE FILLED <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST'(`DR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNIRSS THIS IS A CHANGE OF SITE INFORMATION ONLY.;^ -- <br /> FORM A(3-2-88) Ilk <br /> DATA PROCESSING COPY <br /> L� <br />