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o, b A 7 OF CAMFORQ vi.nR RESOURCES CONTIQBOARD of <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> o <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION i o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C,�FORN P <br /> FO <br /> ARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El7 PERMANENTLY CLOSED SITENE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C,J <br /> CEJ <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Cr1 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS C NEAREST CROSS STREET ✓Box tonWzle ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> TZ� CA <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR 4 PROCESSOR */Box if INDIAN EPA ID # <br /> ❑ ❑ ❑ TRUSTLANDSor ❑ #of TANK's <br /> 1 GAS STATION 3 FARM 5 OTHER 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 If 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 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE IN,WITH AREA CODE <br /> IN. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ADOtlG ADWICISS SHOULD BE USED FOR DOTH 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 8,SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> I I ;;Ll ��m I I , w <br /> CURRENT <br /> 7LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE F ED <br /> © � o��• / 32- YES NO 9 �j g <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> rRM <br /> FORM MUS�_7 <br /> E AMPANIED BY AT LEAST(1)OR MORE TARII PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> (3-2-88) G <br /> 1 DATA PROCESSING COPY �r <br /> ( / v <br />