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OF T <br /> STATE OF CALIFORN10 WATER RESOURCES CONTROIWARD ''EV.[k;'•.N <br /> FORMW: <br /> : UNDERGROUND STORAGE TANK PROGRAM <br /> _c'8Z n`ra� m <br /> r �P M10 <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ELI COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq�FOR"P <br /> MARK ONLY l NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PE Y CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 10 <br /> FACIL TY/SITE NAMECARE OFRESS INFORMATION <br /> ADDRESS 'n NEAR ST CROSS STREE -T �✓ to indicate El PARTNERSHIP ElSTATE-AGENCYN <br /> l4kt16 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME r STATE ZIP CODE SITE P ONE#,WITH AREA CODE IV <br /> CA V_ lI <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ PROCESSOR I/Box if INDIAN EPA <br /> RESERVATION or #of TANK's <br /> ❑ 1 GASSTATION ❑ 3FARM 50THER TRUST LANDS E] W1 OZ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EME GENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: ME(LAST,FIRST) PHONE#WITH AREA CODE <br /> w� a VA <br /> .. NIGHTS: NAME(LAST,FIRST) S P ONE#WITH AREA CODE NIGHT : AME(LAST,FIRST) PH NE#WITH AREA CODE <br /> 0 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME i CARE QqADDRESS INFORMATION <br /> MAILINGor S REET ADDRES ox to indicate El PARTNERSHIP E] STATE-AGENCY <br /> CORPORATION 1-1LOCAL-AGENCY ElFEDERAL-AGENCY <br /> 4. ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTFy,E ZIP CO PHONE#, ITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF AD/RESS INFORMATION <br /> el <br /> MAI G or STREET ADDRESS ✓�o to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> //'' CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP E_,�, � _ PHONE#, ITH AREA CODE <br /> LLUU`P_lJ/� (jam b <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. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> CO[1�1 <br /> UNTY# JURISDICTION# AGENCY# FACILITY ID# #of TTA)NKS,ratt SITE <br /> CURRENT LOCAL GEN E[ <br /> Y FA LITY ID# APP VED Y NAME PHONE#WITH AREA CODE <br /> D <br /> PERMIT R PE IT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 8t� e <br /> LOCATION CODE CENSUS TRACT# SUPE VISOR-DISTRICT CODE BUSINESS PLAN FILED DA FILEgr, <br /> L YES NO ❑ / 1 <br /> CHECK# PERMIT AMOUNT SURCHA GE AMOUNT FEE CODE RECEIPT# On <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 /> FORMA(3-2-88) <br /> • DATA PROCESSING COPY <br />