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STATE OF CALIFORNM WATER RESOURCES CONTRLKL BOARD <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM ^gym <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ?$ _ <br /> `— COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ f NEW PERMIT CHANGE OF INFORMATION 7 ENTLY CLOSED SITE N <br /> ❑ 3 RENEWAL PEflM1T <br /> ONE ITEM ❑ p INTERIM PER 4 AMENDED PERMIT q <br /> ❑ ❑6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> N <br /> FACILITY/SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> NEAREST CROSS STREET ✓gp�ggyyrq EmTwFEmP 13 STATEAGE10 <br /> ❑ cormyATIoN ❑ LOCAACFNCY ❑ FEDBUL-AGE" <br /> CITY NAME ❑ INDMIX)AL ❑ QXNT/-AGENCY <br /> STATE ZIP CODE S TE PHONE N,WITH AREA CODE <br /> >� CA 52 7 u q Z 3 6 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA IU N <br /> ❑ I GAS STATION ❑ B FARM ❑ 5 OTHER TRUERESER LANDS VATION of ❑ N of TANK'N <br /> AT TRIS SITE40 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON <br /> DAYS. NAME(LAST,FIRST) (SECONDARY) <br /> PHONE p WITH AREA CODE OgYS. NAME HAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Bax to in0icale ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LppgL. ❑ STATE-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING ar STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCALAGENCY 0 STATE-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY El FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE <br /> )BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ 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) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N <br /> 3 �n N of TANKS at SITE <br /> O � � 2 z, cT 6 0 U <br /> ERt <br /> ACILITY IDN APPROVED BY NAME <br /> PHONE N WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> SUS TRACTN SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED;/V 2� DgTE FILED <br /> Y/ / YES NOYIT AMOUNT SURCNARGE AMOUNT FEE CODE RECEIPT <br /> BY: <br /> 3 ,Z/- 9v <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 /> FORM A(J-2-8S) <br /> �„ DATA PROCESSING COPY <br />