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OF T... <br /> STATE OF CALIFORNIA WATER RESOURCES <br /> CONTROL BOARD <br /> FORMW: <br /> : - - <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "�FORK P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 10 <br /> FACILITYMSITE NAME ��� �,/) CARE OF ADDRESS INFORMATION <br /> l/ A&ks <br /> ADDRESS Ea�,�' NEAREST CROSS STREET ✓ mdicale ARTNERSHIP ❑ STATE AGENCY N <br /> �/�(/ � �fn( CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY 00 <br /> V/ / V W ElINDIVIDUAL ❑ COUNTY-AGENCY '�MyV� <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE Co <br /> TYPE OF B_W8fNESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> 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#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> & a les I Al. <br /> NIGHTS: NAME(LAST, <br /> F ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS ) PH6NE#WITH AREA CODE <br /> � e <br /> �i <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> 4 p <br /> MAILING or STREET ADDRESS Y_QWf.7ndicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1 ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME- STATE ZIP CODE P NE#,WITH AREA CODE <br /> C,�Gy 93 // <br /> III. TANK OWNER INFORMATION &ADDRESS - (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#,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 /> FPERN <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> EEd I I I j 0 1 1 LCA EV 0 <br /> AGENCY FACILITY ID# APPROVED BY NAME' PHONE#WITH AREA CODE <br /> C <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D LED <br /> �� YES NO <br /> PERMIT AMOUNT SURCHARGE AMOU JiWE60DE RECEIPT# BY: <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 />