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STATE OF CALIFOAIA WATER RESOURCES CONTROL BOARD4v, <br /> h <br /> FORMW: ' <br /> UNDERGROUND STORAGE TANK PROGRAM I'd <br /> SITE %/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } ' <br /> �— <br /> COMPLETE THIS FORM FOR EACH F LITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE �-1 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C) <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) - w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 'w' <br /> L J// <br /> ADDRESS NEAREST CROSS STREET ✓ idnN 0 PAAINERSWP 0 STAT AAGEN0 <br /> ILJ 11IOIV�TION 11 COUNT11 LOCAL AGENCY 11 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA -3 <br /> TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑ 4yR6CESSOR ✓Box it INDIAN EPA ID M <br /> ❑ 1 GASSTATION 3 fARM 5 OTHER RESERVATION or N of TANK'L <br /> ❑ TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> VGl ✓C'/—� <br /> NIGHTS: NAME(LAST,FIRS ) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0CORPORATION 0 LOCAL-AGENCY 1:1 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Com'- ,_ <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> "le G O <br /> MAILING or STREET ADDRESS ✓Box to indicate <br /> 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY O FEDERAL-AGENCY <br /> 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(7)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. - 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 /> COUNTY M JURISDICTION M AGENCY M FACILITY ID X N of TANKS a1 SITE <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME / PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAS#MORE TANK PERMIT FORM 'B'APPLICATION(S), U S THIS IS A CHANGE OF SITE INFORMATION LY. <br /> FORM A(3-2-aB) <br /> "�0 DATA PROCESSING COPY <br />