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rM1f <br /> .+�E OF CALIFORNIA-� WATER RESOURCES CONTROL�OARD *. <br /> JRM 'A': <br /> SITE UNDERGROUND STORAGE TANK PROGRAM u �" <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION P r Z <br /> C---Ad— COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY /NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1--& <br /> ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W <br /> FACT TY/SITE NAME CARE OF ADDRESS INFORMATION N <br /> ADDRESS NEAREST CROSS STREET ✓Baitoodere ❑ PA NOtSHIP ❑ STATE AGM <br /> ❑ calroaenav Cl WCALAGENLY [I KDERAtAri <br /> ❑ INomoUAL ❑ 001JIM AGEND <br /> CIN NAME STATE ZIP CODE SITE PHONE p.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS', ❑ 2 DISTRIBUTOR ❑4PROCESSOR ✓BOX If INDIAN EPA ID N <br /> ❑ T GAS STATION ❑ 3 FARM E] 5 OT <br /> TRUST LANDS ATION or ❑ - N AH TANK1 <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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Be.✓ to indicate ❑ PARTNERSHIP_0STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH ARTA COOS <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. ❑ it. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID R N of TANKS BI SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> G 36 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILED <br /> YES NO ❑ <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN 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 INFORMATION ONLY. <br /> 1 FORMA(3-2-88) — - <br /> `r DATA PROCESSING COPY `/' <br />