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- <br /> ° GF C'AF WATER RESOURCES COMTROL BOARD <br /> fSEP ;'•' TN\ <br /> UMDERGROUNID STI ORAOI: TARN( PROGRAMi m <br /> ACI?ITV/SITE, I FORRLATION! acid/or PERMIT APPI_ICATI01 <br /> � ° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq,IFORNn <br /> ARK ONLY ❑ � NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑2-IL <br /> 7 ENTLY CLOSED SITE <br /> ONE ITEL ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. I=ACILITY/SITE INFORC ATIOM &ADDRESS — (MUST BE COF�PLETED) <br /> FACILITY/SITE NAMM�� <br /> Vo p(,.. CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box la Irdicate Cl P RTNERSHIP ❑ STATE-AGENCY <br /> L0 J' /I t I��j / ,* ❑ CORPORATION -AGENCY ❑ FEDERAL-AGENCY <br /> f 7 1 ❑ INDIVIDUAL COUNTY-AGENCv <br /> CIN NAME STATE ZIP CODE SITE PHO N #,WI EA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK's -7 <br /> ❑ I GAS STATION F__] 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE j9�" <br /> EMERGENCY CONTACT PERSON(PRIR5ARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA COI)E DAY,$: N ME(LAST,FIRST) #WITH A EA CODE <br /> G�r �o �- ,,PHONE <br /> NIGHTS: NAMk(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LA FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWXER IMFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME _ r �• -, '?:' /�- CARE OF ADDRESS INFORMATION�s.A�i l 6J/���� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> � ❑ CORPORATION Q LOCAL-AGENCY FEDERAL-AGENCY <br /> � <br /> r ❑ INDIVIDUAL R•COUNTY-AGENCY <br /> CITY NAME STATEr 1 ZIP CODE PHONE#,WITH AREA CODE <br /> III. TAMN OWMER [OFORLLrATiOk &ADDRESS— (GUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IN. LEGAL NOTIFICATIOM AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING VNICI2 AGOVE ADDR308 SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ 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 AGEMCY USE ONLY <br /> ter'.-.�.: ..-: ,,.•..:;.�— mc,..v: .. e>:�.__ .r.�.. '.� - <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ig <br /> FT)Fl /-1 L <br /> - - <br /> 4 CURRENT LOCAL AGENCYYACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE i..� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOD1STRICTCODE BUSINESS PLAN FILED DATE FILED <br /> _� 6) YES ❑ NO ❑ .� <br /> CHECK# PERL:IT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM„UST BE ACCOL:PANIED BY AT LEAST(1)OR MORE TAPTX PERUIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORVATION ONLY. <br /> FORM A(3-2-88) <br /> LOCAL::02.= COPY �-� <br />