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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM '/4': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION " s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> i <br /> MARK ONLY ❑ I NEW PERMIT _j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE )V <br /> ONE ITEM Z INTERIM PERMIT El 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE /J <br /> fJl <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME <br /> SARA, CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS BTREET ✓gp moods ❑ pegiryEIS11IP ❑ SiAiE AGF71L1' <br /> El COR'gHAiKKI ❑ IOGl-AGENCY ❑ IEOFAPI..IGENLY <br /> CITY NAMEElINUVIBIAI ❑ COINttAGENLY <br /> 57«sem STATE ZIP CODE jSITE PHONE p,WITH AREA CODE <br /> CA S^2O <br /> TYPE OF BUSINESS: 02 IBUTOR 4 PROCESSOR ✓Box it INDIAN EPA IU N <br /> 0 1 GAS STATION ®3 FARM ❑5 OTHER RESERVATION or ❑ F of TANK's <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) TRUST LANDSEMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIR ) PHONE A WITH AREA CODE NIGHTS: NAMELAST.FIRST) <br /> ) PHONE If WITH AREA CODE <br /> Ii. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE A,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> n� � CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Vl '/00.to lnd.cale ❑ PARTNERSHIP <br /> ❑ CORPORATION ❑ LOCAL-AGENCY 0 STATE-AGENCY <br /> ❑ ❑ FEDERAL-AGENCY <br /> CITY NAME INDIVIDUAL ❑ COUNTY <br /> STATE ZIP CODE PHONE 4.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. 0 II. 0 HL EJ <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 M JURISDICTION N-n AGENCY R FACILITY ID R <br /> F of TANKS at SITE <br /> D o / 7 o <br /> CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME <br /> L /� PHONE AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PLOCATIONCODE 'CENSUSTRACT• `SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILEDDATE FILEDZ YES NO y moi/ 9PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE / �77j�q <br /> __ - RECEIPT eyW/v/ <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 /> MIA(3288) t� <br /> 1VLI1V/II i d�1C�� � DATA PROCESSING COPY <br />