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STATE OF CALIFOR vfWA WATER RESOURCES CONTlri L BOARD. <br /> • r <br /> FORAM `A: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 'S l ' <br /> COMPLETE THIS FORM FOR EACH FA ITY/SITE Cq FOR.., <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMAN LY CLOSED SITE <br /> ONE ITEM E]2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUREf3 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAR!aw <br /> TREET ✓Box tordale ❑ TNMIP ClSTATE-AGENCY <br /> � s'� ❑ CORPORATION LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> f VJ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE it.WITH AREA CODE <br /> CA I J <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ PROCESSOR ✓Box if INDIAN EPA 10 a <br /> RESERVATION or M of TANK's <br /> 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE II WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It 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 ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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 /> Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE$1,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: 1. ❑ II. ❑ 111.❑ <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# JURISDICTION IT AGENCY 8 FACILITY ID M k of TANKS at SITE <br /> I I LJ E I I I lo 10 FiA, ff 5 �21 <br /> CURRENT LOCAL AGENCY FACILITY 10• APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMO APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVIS -DISTRICT ODE BUSINESS PLAN FILED DATE FILE T <br /> D v �y� 31 YES [-] NO (J <br /> CHECK# PERMIT AMOUNT SURCHAR6E AMOU T FEE CODE RECEIPT M BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT*(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONNLESS THIS IS A CHANGE OF SITE INFOR ION ONLY. <br /> FORMA(3-2-88) <br /> —`O--;A DATA PROCESSING COPY `� <br />