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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS 1 " <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE r w f <br /> MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION El PERMANENTLYCLOSED SITE rV <br /> ONE,ONLY <br /> ❑ p INTERIM PERMIT ❑ Q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r, a•" <br /> QF <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) X -' <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> e f•L o,✓ �rYrc <br /> ADDRESS NEARESTCROSSSTREETTO <br /> Qmale ❑ PARTNERSHIP O STATEAGENCYf pzf�'Ifi AJ El RanoN ❑El LOCAL ❑ FEDERAL-AGENcv <br /> CY <br /> CITY NAME STATE CODESITE PHONE#.WITH AREA CODE <br /> CA 7,x.2 _ —Y5 <br /> TYPE OF BUSINESS. ❑ ISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ 1 GAS STATION J1 3 FARM ❑ 5 OTHER RESETRUER LANDS VATION o ❑ #of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> fis 2a?- 6:r`- <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �S <br /> MAILING or STREET ADDRESS Be.✓ toind,doe ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION O LOCALAGENCYO FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CTT(NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate O PARTNERSHIP O STATEAGENCY <br /> ❑ CORPORATION O LOCALAGENCYO FEDERALAGENCY <br /> O INDIVIDUAL O 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. TmtjII. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER 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 /> COUNTYIN JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [ail <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE It WITH AREA CODE <br /> Ii= ; LF_ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES [:] NO <br /> CH C # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTp BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT II MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-RSJ • <br /> DATA PROCESSING COPY <br />