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i, <br /> ygP®u 00,STATE OF rNF <br /> v WATER RESOURCES CONTRAOARD <br /> FORM ' <br /> 7® UNDERGROUND STORAGE TANK PROGRAM <br /> t d <br /> SITE 7INFORMATION PERMIT APPLICATION <br /> COMPLETETHIS FORM FOR EACH FACILITY/SITE °gOFORE ARK w�P <br /> ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE <br /> M: <br /> 1. FACILITY/SITE FACILITY/SITEINFORMATION - ( ) <br /> FACILTT(/SITE NAMX. / CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST C OSS STREET ✓Boz tomdicme ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 1 ❑ INDMDUAL ❑ COUNTY-AGENCY <br /> CITY NAME E/,® STATE ZI CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'>s <br /> SERATION <br /> 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS®r AT THIS S <br /> EMERGENCY CONTACT PERSON(PRIMARY) Y CONTACT PERSON(SECONDARY) <br /> DAYS: NAME ST,FIRST) PHONE It WITH AREA CODE DAYS: NAM (LAST,FIRST) PHONE#WITH AREA CODE <br /> a g4 4 1 -7 <br /> NIGHTS: NAME(LA§T FIR?t) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ZA-: <br /> 1 ® PROPERTY OWNER INFORMATION ) <br /> NAME CARE OF ADDRESS INFO MATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> (� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> / r J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME I STATE ZIP CO E PHON #,WITH AREA CODE <br /> 5/ <br /> Ill® TANK OWNER INFORMATION ) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATIONBILLING <br /> [­CHECK ONE(1)BOX INDICATING WHICN ABOVE ADDRIISS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. El 11. ® 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 /> FNSER <br /> JURISDICTION AGE CY# FACILITY I #of TANKS at SITE " <br /> Lj 0 0 1,7 <br /> 016 1 A 31 A __L_Lj <br /> AGEMC ITV ID# O BY NAME PHONE#WITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CEN STRACT# SUPERVISOR-DI 1 C BUSINE FILED27-3 9-0 r YES O <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM UST BE ACCOWANIED BY AT LEAST(1)OR MORE T 'B' APPLICATION (S),UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br />