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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , IZO <br /> EjCOMPLETE THIS FORM FOR EACH FACILITY/SITE �'"•a^"'" <br /> MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I� <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 5 <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> O <br /> FACILITI'/SITE NAME CARE OF ADDRLESS INFORMATION <br /> e LY2 Mar air a lueffo4+ 3 <br /> ADDf � NEARESTCN$S STREET ✓Bpbidime ❑ PAAFERp El STATFAGBC! <br /> ORMnON ❑ LOGG ❑ FFDUKAGE10 <br /> 146 7 tS„yj <br /> ROMIDLA4 ❑ CuJITAOENC/ <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> raCA 53 - <br /> TYPE FBUSINE ❑ y DISTRIBUTOR ❑4 PROCESSOR I ✓Box 6INDIAN EPA ID N <br /> E] 1 GAS STATION ❑ 3 FARM 5 OTHER TRUSTYLANDS m ElATITHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST,FIRST PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 2 - 3 KN <br /> NIGHTS' NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> eFf>^u -8 J'7 <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> F 45 <br /> MAILING or STREET ADDRESS -/Ed.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 If,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> s MF AS <br /> MAILING or STREET ADDRESS ✓Box to indicate ['PARTNERSHIP 0STATE-AGENCY <br /> O CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 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. el 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 /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N If of TANKS at SITE <br /> E I'1� O 6:El 10101010 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMRAPPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENWS TRACT III SUPERVISOR-0ISTRICT CODE BUSINESS PIAN FILEDDATE ILED <br /> 2300 `7�1 YES [:] No ❑ / c <br /> NECK# PERMIT AMOUNT SURCHSURCHARGEE CODE <br /> SURCHARGE AMOUNT FERECEIPT# BY: <br /> 'S 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 /> S. DATA PROCESSING COPY ..� <br />