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�+�+F-��- .m-� .,�;.,-.,,.y.,, pnp,.,,ns;3''�' 7�^!�n^v;•rr--,..-�-._-. ., <br /> i' <br /> STATE OF CALIFORNIA* WATER RESOURCES CONTROOERRD <br /> FORM W: <br /> UNDERGROUND STORAGE TANK PROGRAM b <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ��� o <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED SITE F a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION&A ESS--(MUST BE COMPLETED) <br /> N <br /> FACR_I /SITE NAME , L, i CAREOFADDRESSINFORMATION <br /> (5k r.) vd//err_ <br /> ADDRESS NEAREST CROSS STREET ✓bt 10 ht* ❑ PARTIV&P ❑ SUIE-AGDIGY <br /> ACJ (/i1 J ❑ <br /> WWWTO ❑ LOM AGM ❑ ITDUUL-AGM <br /> �-�✓ ❑ IRtXYwl ❑ OOLamdfi y <br /> CITY NAMEG STATE P CODE SITE PHONE:Y,WITH AREA CODE <br /> V'a't aVlj CA SA06-- <br /> TYPEOFBUSINESS: ❑ STRIBUI.OR ❑41"ROCEm ✓B INDIAN EPA ID N <br /> RESERVATION ot Y of TANX'I <br /> 1 GASSTATION 3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION&ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Dox to ndicalc Q PARTNERSHIP Q STATE.AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ____ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE.OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Dox to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ rEDERAL•AGENCY <br /> ❑ INDIVIDUAL Q COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,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. 1. ❑ III.❑ <br /> THIS FORM HAS OEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE DEST OF MY KNOWLEDGE,FS TRUE AND CORRECT. <br /> APPLICANT"S NAME(PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION P. AGENCY N FACILITY IDA X o1 TANKS at SITE <br /> [ _ oo Ld <br /> CURRENT LOCAL A E Y A ILI J ^ APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT I SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE ILED <br /> 23 �S— YES <br /> CHECK I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> fORM A(3-2-SS) <br /> DATA PROCESSING COPY <br />