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STATE OF CALIFORNIA► WATER RESOURCES CONTRO OARD <br /> FORM IIA': <br /> UNDERGROUND STORAGE TANK PROGRAM =`moo Z <br /> .; <br /> 10 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONne- Cq;1Fo p�`P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMA, NTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE F-A. <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) O! <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME <br /> Tt✓ A26 GO <br /> ADDRESS NEAREST CROSS STREET ✓Bpr le ❑ PARTNERSHIP ❑ 57ATE-AGENCY <br /> L-AGENCY� /� RPORATION ❑ LOCAL-AGENCY ❑ FfDEAAL�AGENGY <br /> ClINDIVIDUAL ❑ COUNTYAGENCY <br /> I"'I V V Mv, 1 G ! V 57ATE ZIP CODE SITE PHONE#.WITH AREA CODE <br /> CITY NAME n , ` � CA <br /> TYPE OF BUSINESS: <br /> F-1 2 DISTRIBUTOR ❑ 4 PROCESSOR Box it INDIAN EPA ID # —[ rAT <br /> ofTANK"I <br /> 5 OTHER RESERVATION or HIS SITE <br /> ❑ 1 GAS STATION ❑3 FARM ❑ TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> GAYS' NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE DAYS, NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS, NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#.WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate E3 PARTNERSHIP ElSTATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE 21P CODE <br /> PHONE#.WITH AREA CODE <br /> CITY NAME <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. El III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# #of TANKS a1 SITE <br /> FJ �i F I El <br /> Lj <br /> CURRENT LOCAL AGENCY FACILITY 10# <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> DATE FILED <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS <br /> $NFILED NO <br /> CHECK 11 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(SI,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> 40 DATA PROCESSING COPY <br />