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OF <br /> STATE OF CALIFORNO WATER RESOURCES CONTA BOARD <br /> FORM ' <br /> '. <br /> ® UNDERGROUND STORAGE TANK PROGRAM 7 <br /> Y fto <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE IS FORM FOR EACH FACILITY/SITE `'IFORN'EMARK " <br /> L ❑ 1 NEW PERMIT ® 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> E ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ®6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION — ) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> %qf-p,e—. <br /> ADDRESS NEAREST CROSS STREET ✓Ba toee ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ RDERAL-AGENCY <br /> 64 Cl INDMOUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS: F7 2 DISTRIBUTOR ®4 PROCESSOR ✓Box if INDIAN EPA ID It <br /> 1 GAS STATION ®3 FARM ®5 OTHER Cs <br /> TRUST LANDS ESERVATION or ❑ A of HISTANSITE AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CTACT 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#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 /> MAVONG 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 /> 111. TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> IV. LEGAL NOTIFICATIONILLI <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ I1. ❑ 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 /> AGENCYLOCAL USE ONLY <br /> COON # JURISDICTION AGENCY FACILITY ID# #of TANKS at SITE " <br /> r <br /> CURRENT LOCAL AGENCY FACILITY ID# ROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L TION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS N FILED DATE FILED <br /> YES NO L 190 <br /> / CHECK# PERMIT AMOUNT SURCHARGE AMOUNT RECEIPT# BY: <br /> IS FORM MUST BE ACCO IED BY AT LEAST OR MORE TAPPLICATION(S), U SS THIS ISA CHANGE OF SITE INFORMATION ON <br /> FORM A(3-2-88) <br /> '2 <br /> ® a <br /> S <br /> t� <br />