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r <br /> STATE OF CALIFORNIA► WATER RESOURCES CONTROL BOARD <br /> FORM PAI: UNDERGROUND STORAGE TANK PROGRAM Ado <br /> SFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ®o ;P <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE O <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/ ENA CARE OF ADDRESS INFORMATION <br /> NEAREST CROSS STREET ✓COVDtiu# ❑ PARINERiHIP 0 STUFAGENCY <br /> AGEN <br /> ADDRESS_ ❑ INIAMM4TlBN ❑ LBG4-AGENGY ❑ fE�EWLL-1f+ENLY <br /> J/j ❑ INgVIWN ❑ fAUNfY-AGENCY <br /> CITY NAME /� ,rte STATE DECODE SITE PHONE A.WITH AREA CODE <br /> NAMES <br /> CA qsa� (o <br /> TYPE OF SINESS. 2 OISTRIBUTOfl 4 PROCESSOR ✓Box if INDIAN EPA ID # #o1 TANK's <br /> ❑ ❑ RESERVATION or AT THIS SITE <br /> 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ <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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. ❑ IL ❑ It.❑ <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 /> COUNTY# JURISDICTION If AGENCY# FACILITY ID At #of TANKS at SITE <br /> 0 ) 0 1(�) 10 1 col <br /> CURRENT LOCAL AGE Y FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 3S <br /> PERMIT NU BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION;PE CENSUS TRACTih O 8UPERVISORDI TRIODE BUSINESS PLAN FILED DATE FIL D j <br /> (O�/ YES NO � "` <br /> CHEC # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'BI APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-&S) V C <br /> l4,.R/ DATA PROCESSING COPY <br />