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, ATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> A <br /> 'ORMW: <br /> : UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION F ITY/SItE $� ,4 �! 0 4 <br /> COMPLETE THIS FORM FOR EACH '`'FSR-" <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 CLOSURES <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ❑ PARTNERSHIP ❑ STATE-MEN(Y ` <br /> L ` / TION 13LOCAL-AGENCY 11 FEDERAL-AGOG <br /> T <br /> L T L ,t DUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE'!, SITE PHONE k.WITH AREA CODE <br /> CA ��+ 921— <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PR ✓Box it INDIAN EPA ID k <br /> RESERVATION or k of TANK'si <br /> ❑ 1 GAS STATION El FARM OTHER TRUST LANDS ❑ ul ATTHIS SITE <br /> i EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> GZ ,G/ O <br /> NIGHTS: NAME(LAST,FIRST) PH NE k W H AREA CODE NIGHTS: NAM <br /> E(LAST.FIRST) PHONE k WITH AREA CODE <br /> [ to— <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑je6RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boxt dicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> El -ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> DIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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: I. ❑ 11- 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 /> FPENUMBYE <br /> JURISDICTION k AGENCY k FACILITY ID k k of TANKS at SITE <br /> [E�l D � 1 ,� 13172oa <br /> AGEN FACILITY ID APPROVED BY NAME PHONE k WITH AREA CODE <br /> • l.. I4 rt / <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT I SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE Flei 49 3 3a YES ❑ NO ❑PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE r -UPT k BY: <br /> MEMO <br /> . ' <br /> A, THIS FORA MUST BE ACCOMPANIED BY AT LEAST(1 1 <br /> MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMA 0N ON <br />