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I,yvn-«-�:.-.r..,yg;.,n.'nnen.r, r.T.eK�,-aeF.�..,.�..—'•"'RfGi�rl�+77-71 7-7-7717'"77 <br />n;. <br />STATE OF CALIFORNO WATER RESOURCES CONTROL BOARD <br />FORM`A': WSA <br />UNDERGROUND STORAGE TANK PROGRAM <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE CgQFpRN P <br />MARK ONLY w 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I <br />ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ®, <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />FACILITY/SITE NAME <br />zo /Cm <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />E&IL MPt t f <br />ADDRESS <br />✓ to indicate El PARTNERSHIP ❑ STATE -AGENCY <br />El <br />CORPORATION LOCAL -AGENCY FEDERAL -AGENCY <br />NEAREST CROSS STREET <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />ZIP CODE <br />STATE <br />CA <br />ZIP CODE <br />SITE PHONE #, WITH AREA CODE <br />TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR <br />1 GAS STATION 3 FARM <br />❑ ❑ <br />❑ 4 PROCESSOTRESE <br />❑ 5 OTHER <br />Box if INDIAN <br />RUSTVA ON or <br />❑ <br />EPA ID # <br />DATE ILEO <br />3 ' q I <br /># of TANK's <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />DAYS: NAME (LAST, FIRST) <br />PHONE If WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />E&IL MPt t f <br />MAILING or STREET ADDRESS <br />T-�' <br />✓ to indicate El PARTNERSHIP ❑ STATE -AGENCY <br />El <br />CORPORATION LOCAL -AGENCY FEDERAL -AGENCY <br />INDIVIDUALN Cl COUNTY -AGENCY <br />CITY NAME <br />STATE <br />��jClW4uQ'dZ1�-� <br />ZIP CODE <br />PHONE , WITH AREA CODE <br />— 7 <br />I11. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING or STREET ADDRESS <br />✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY <br /># of TANKS at SITE <br />❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />❑ INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #, WITH AREA CODE <br />IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br />I CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III. V <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 />C"OOUNTY # <br />V <br />JURISDICTION # <br />AGENCY # <br />FACILITY ID # <br />( I <br /># of TANKS at SITE <br />CURRENT LOCAL AGENCY FACILITY ID # <br />SWI 1 IV <br />APPROVED BY NAME PHONE #WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />LOCATION CODE <br />® <br />CENSUS TTRACT # <br />23, <br />SUPERVISOR -DISTRICT CODE <br />�J <br />BUSINESS PLAN FILED <br />YES NO <br />DATE ILEO <br />3 ' q I <br />CHECK # <br />PERMIT AMOUNT <br />SURCHARGE AMOUNT <br />FEE CODE <br />RECEIPT # <br />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 �: � <br />