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STATE OF CALIFORN..., WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PROGRAM :" w" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM SED SITE li-16 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> W <br /> 1. FACILITY/SITE INFORMATION ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME _ CARE OF ADDRESS INFORMATION <br /> XXo <br /> ADDRESS /� NEAREST CROSS STREET ✓GO to tr4i 0 PARTNERSHIP ❑ STATE AGENQ' <br /> P 0 CDAPURAPUN 0 LOCAL AGENCY 0 FEDERAL AGENCY <br /> P0_Q- - ❑ INDMDNAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I -/Box it INDIAN EPA ID N <br /> RESE❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUSTMLANDS ATION dr ❑ AT THIS SITEOf TANKY O <br /> A <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTYAGENCY <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 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL AGENCY <br /> 0 INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE b,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. ❑ if. ❑ 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 Or AGENCY# FACILITY NO k A of TANKS at SITE <br /> a0 a <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE4CODE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTBUSINESS P5 N❑FILED NO IATE FILED <br /> CHECKN PERMIT AMOUNT SURCHARGE AMODE RECEIPT M BY: (I BJ\ <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 ONLY5 <br /> RM A(3-2-8B) <br /> we <br /> DATA PROCESSING COPY <br />