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0 <br /> TATE OF CALIFORN1 WATER RESOURCES CONTRO�BOARD <br /> S �= s� <br /> FORMW: <br /> : <br /> UNDERGROUND STORAGE TANK PROGRAM w 'gym <br /> SITE FACILITY/SITE, INFORMATION and/o PERMIT APPLICATION Y ° , �� <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IN 5 CHANGE OF INFORMATION ❑ 7 PERMA Y CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1 111 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> .5*4 r -T <br /> ADDRESS NEAREST CROSSSTR ET ✓Boz toinCicate El PARTNERSHIP ❑ STATE-AGENCY <br /> � <br /> s El CORPORATION 1:1 LOCAL-AGENCY 1:1 FEDERAL-AGENCY <br /> / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE CZIP / SITE PHONE^,WITH AREA CSE <br /> A <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID If G/# (TNK's V_ <br /> ❑ ❑ ❑ STLANDS <br /> or ❑ #of TANK's <br /> 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(JAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAIAEKAST,FIRST PH N,EE##WITH AREA CODE NIGHTS: NAME(LAST,F�rS�T PHONE#�WIITH AREA COO/DE <br /> 71 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS-IMUST BEC MPLETED) <br /> NAME MAP I IG WO CARE OF ADDRESS INFORMATION <br /> MAILING or STR TV Box to indicate ❑ PA TNERSHIP 11STATE-AGENCY <br /> ❑ CORPORATION CAL-AGENCY 13FEDERAL-AGENCY <br /> 0 F ❑ INDIVIDUAL LU COUNTY-AGENCY <br /> CITY NAME STATE _ ZIP CO2w/ PHONE 4,WITH AREA COiE <br /> 4::� l Itig' VW_o?_k27 <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 /> ❑ 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 ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. K 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 /> FPERMITNUMBER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> F-3- Loldl_1111 (11 :11o0 os <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 2/ 8o YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Y: <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 />