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STATE OF CALIFORNIA WATER RESOURCES CONTROL BL OARD "•'° • 'F <br /> FORMA": UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' : I o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'A�.ow�•" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENT ITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> f s u� <br /> ADDRESS ab pNEAREST CROSS STREET ✓ b 0 PAATNER'S111P ❑ STATE AGENCY <br /> G G <br /> TO0 LUGL-AGENGY 0 FEDERAL AGM <br /> L 0 COUn-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE <br /> cS�o c,E CA �I S aos <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR Box if INDIAN EPA ID a <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS VATION of ❑ / M T14IS SI <br /> u ((/ AT THIS SITE D/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) /,� PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST)/� PHONE N WITH AREA CODE <br /> "A- � 0Ce_ <br /> NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FI ) PHONE a WITH AREA CODE <br /> le— <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE CO(,/MC/PLLETED) <br /> NAME CARE OF ADDRE SINFORMATION <br /> � a sA9 <br /> MAILING or STREET ADDRESS of icate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> RATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> IVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STA ZIP CODE PHONE p,WITH AREA CODE <br /> S <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST (E COMPLETED) <br /> NAME - CARE OF ADDRESS INF TION <br /> MAILING or STREET ADDRESS ✓Be to IKcat. 0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> S <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. II. ❑ 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 /> COUNTY N JURISDICTION M AGENCY B FACILITY ID R B of TANKS at SITE <br /> 3E I a I o I V= ID 1 d v / <br /> CURRENT LOCAL AGENCY FACILITY ID N� APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> / LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> (( ( <br /> CHECK PENT AMOUNT SURCHARGE A NT FEE CODE YES ❑RECEIPT FIf ❑ I 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 /> FORM A(3-2-88) <br /> �' DATA PROCESSING COPY A�"� IS <br />