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STATE OF CALIFORNIA WATER RESOURCES CONTROL toARD (lS <br /> `°"`"'\�� <br /> `A': <br /> UNDERGROUND STORAGE TANK PROGRAM W <br /> FORM <br /> SITE 11ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Y Ma <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ~`°pP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G G o <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME _ CARE OF ADDRESS INFORMATION <br /> NEAREST CROSS STREET ✓ n kale El PARTNERSHIP ClSTiATE�AGENCY C rD <br /> ADDRESS DRPOFATIgN ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 'm <br /> (I M r N ❑ NiI ❑ COUNTY-AGFNGY C:) <br /> CITY NAME STATE ZIP CODE S -PHONE&,WITH AREA CODE <br /> CA -3 G <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR E:] SSOR 4 PR RESERVd INDIAN ATIONRVAT40N or EPA IC t #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) ONE 4 WITH AREA CODE DAYS, NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST PHONE H WITH AREA CODE NIG TS. NAME(LAST,F STI PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPL TED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME / _r+ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate Ll PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CUPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> IDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE P NE 4,WITH EA 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, I'S 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 E01c) L), 13131 ) 1 clici C) I I I <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROY BYNAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRI fCT CODE BUSINESS KLAN FILED DATE FILED <br /> 7- ` I 1 YES ® NO ❑ ���r <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE REGEIPT# 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 INFORMATIOZON <br /> . <br /> 'FORMA(3-2-85) <br /> DATA PROCESSING COPY <br />