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STATE OF CALIFORNI)v WATER RESOURCES CONTROL BOARD = `" <br /> UNDERGROUND STORAGE TANK PROGRAM =" <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 V CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE V ,/ <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS //� NEAREST CROSS STREET ✓Bwb Mule ❑ PMfNOW 0 STAMAGOO <br /> 12,4_76 !/ �L✓/� °o INu�An«DNOJk 0 i G ❑ FOBwA FM <br /> Cf <br /> CITY NAME �/ STATE ZIP COD SITE PHONE N,WITH AREA CODE <br /> CA 9��� zoo'- 62Gro9 <br /> TYPE OF BUSINESS. ❑ 2 DISNIBUTOR ❑ 4 WESSOR ✓Sox4INDIAN EPA ID NRESEF0I TANK'a <br /> ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS ATIONdl ❑ 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 N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY 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 ❑ FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING oe STREET ADDRESS ✓Sax toindicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 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 WNICN ABOVE ADDRBBB SHOULD BE USED FOR BOTN 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 R JURISDICTION R AGENCY M FACILITY ID E R of TANKS N SITE <br /> CURRENT LOCAL AGENCY FACILITY 1 APPROVED BY NAME PHONE 4 WITH AREA CODE <br /> 'rl�)• Ar- <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACTS SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / <br /> 7; Z 2 YES MOO 7 <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY�y� <br /> THIS FORM MUST BE ACCOWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS M A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> re <br />