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STAirE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> Wim, •s <br /> FORMW: UNDERGROUND STORAGE TANK PROGRAM � l �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACHCILITY/SITEZW <br /> MARK ONLY Er NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMIATION <br /> ADDRESS oar <br /> NEAREST CROSS STREET ✓80-10 indicale ❑ PARTNERSHIP ❑ STATE-AGENCY }•-i <br /> �• C../!—T�"if'� I Y Cl CORPORATION ClLOCAL-AGENCYClFEDERAL•AGENCY Co <br /> CI-IADNIOUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIE,C SITE PHONE#,WITH AREA CODE <br /> d CAS-f�i 1 -- q 22 <br /> TYPE OF LISINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> 1 GAS STATION ❑3 FARM ❑5 OTHER TRUSTVATION LANDS or If 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 DAY NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST }RS 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 ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Ll-CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> W� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> C-td. `i ICc <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> G�,�t�-t�' Leh 4e�o�✓E <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#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOV8 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ it. Ill.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICA 'S NA PRIN &SIGNATU `� DATE <br /> LOCAL AGENCY USE ONLY <br /> - <br /> c <br /> COUNTY# JURISDICTIONS AGENCY41, FACILITY ID# #of TANKS at SITE <br /> m I I I J EI I I Li—I k I os S <br /> -I I I 1-f�l <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> T IFZ, <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> Y <br /> LOCATION CODE CENSUS TR T# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> . , a0 YES [—] NO <br /> Lu <br /> K I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODER ECEIPT# 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 /> FORM A(3-2-88) ; <br /> DATA PROCESSING COPY <br /> . _ f <br />