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,' '�'ST:�?�RiTa't`TI1�'�"'� .:xarq•'o'+k�-n-v'rs-wletFy*l.-"',.. .. .. •� <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD z �" <br /> FORM : UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY'CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 10 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACII}'(V'/SITE NAMED �� b/ ` CA F ADDRES INFORMATI N � 4 <br /> (/�/I V N <br /> ADD 51 NEAREST CROSS STREET ✓EaxWimXcale E/BIIP ❑ STATE-AGDo (ff <br /> ! (�.�� ❑ CORPORA110N LOCN-AGENCY 0 FEDERAALAGBIC! <br /> (VCW ❑ MOIVIOUAL l%IIt AGENCY <br /> CITY N E STATE ZIP CODE SITE PH NE N.WITH AREA CODE <br /> CA ? -()C-? <br /> TYPE OF BUSINESS: p DISTRIBUTOR ❑4 PRDCESMR I ✓Boz it INDIAN EPA ID a #of TANK's <br /> RESERVATION <br /> ❑ 1 GAS STATION ❑3 FARM 05 OTHER TRUST LANDS or ❑ (• AT THIS SITE d V <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LASF,FIRST) PHONE a WITH AREA CODE DAYS: ME(LAST,FIRST) PHONE#WITH AREA CODE <br /> A 64-66?(o A t A <br /> NIGHTS: NAME(LAST, IRST) PHONE#WITH AREA CODE NIG : NAME(LAST.FIRST) PH NE a WITH AREA CODE <br /> 5 A PA f AA <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> 7D <br /> MAILING or STREET ADDRESS -/Box to i,kicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> I <br /> 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGor STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,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. E:r 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 /> II1� COU IIIINT`Y## II JURISDICTION# AGENCY# FACILITY ID A #of TANKS at SITE <br /> 2 /) �f [� d <br /> CURRENT LOCAL AGENCY FACILITY 10 If APPROVED 8Y NAME PHONE N WITH AREA CODE <br /> OA K L11-7 <br /> PERMIT NUMBER PERMIT APPROVAL DATELCODE <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT* SUPERVISOR-DISTRBUSINESS PLANFILED DATE FILEDYES � NO /D // <br /> CH CKk PERMIT AMOUNT SURCHARGE MOUODE RECEIPT# 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 INFORMATIO ONLY. <br /> PMA(3-2-SS) <br /> DATA PROCESSING COPY �, <br />