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yE�OF <br /> STATE OF CALIFORNIA 1 X r f <br /> WATER RESOURCES CONTROL BOARD <br /> FORMW: <br /> : UNDERGROUND STORAGE TANK PROGRAM 0 <br /> _`� m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> gCIFO R RNP <br /> MARK ONLY f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE Y CLOSED SITE IV <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ellvA <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SIjTE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEIINREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ClFEDERAL-AGENCY <br /> lC/�✓/✓j � 1 G'� ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> ILo-PI CA S2`� 2d� 3Co8 3 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> Is 1 GAS STATION 3 FARM 5 OTHER RESERVATION or /+� �, <br /> [:] ❑ TRUST LANDS ❑ �-i'►vAT 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 /> 5 I o,,! _mss ;wlM <br /> NIGHTS: �A�LAST,FIRST) cillo PHONE#�TH A�CODE NIGHTS: NAME(LAST,FIRST) �(�H��AREA CODE <br /> 15-WII. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> /' <br /> W, -- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ° ° DZ ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CI NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> G� 2 S [Q7(o 141 <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET AD DR ✓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: 1. ❑ 11. ❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> AP LICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> C 5 n <br /> LOCAL AGENCY USE ONLY <br /> F <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> AGENCYFACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> FR ECORT, <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENaSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDDATE F LED <br /> d, 3 i c YES � NO � 1b MPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY 0 5 <br />