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ATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> rr. sx <br /> i f <br /> IRM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,.> ' <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE IFO"" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT, �5 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) , <br /> FACILITY/SITE AME s CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓ o : ❑ PARTNAIP ❑ STATE-AGIRC <br /> * ❑ LOCALAXNCY ❑ FEDEMLAGM <br /> u � <br /> COUNTYAGENcr <br /> CITY NAME�R.-,-- = a_ STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA a 5210 (v <br /> t2. .; <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 P R ✓Box H INDIAN EPA ID N b- <br /> EMERGENCY <br /> RESERVATION or E of �I t GAS STATM ❑ 3 FARM OTHER TRUST LANDS , ❑ AT THlS SITE CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS', NAME{LAST,FIRST! PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRSTS - PHONE N WITH AREA CODE <br /> .i <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMA ION & 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 ❑ FEOERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY ik <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE, <br /> III. TANK OWNER INFORMATION &ADDRESS qMUST 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 ATE ZIP CODE - PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING NICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LE NO <br /> MITIFICATION AND BILLING: L ❑ 11. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE ST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) - RATE - - <br /> LOCAL AGENCY USE ONLY 3 <br /> FPERMITNUMBER <br /> JURISDICTION M AGENCY 8 FACILITY IDS M of TANKS N SITE t <br /> Em, [01010-Rd <br /> I <br /> LOCALAGENCY FACILITY IDN _s: I APPROVED BY NAME PRONE R WITH AREA CODE+ <br /> a(y <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACTT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI DYES ❑ NO` �PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 01111 MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ir <br /> FORMA(3-2-88). .r 4 <br /> Ji A <br /> Y \ ��- <br />