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STATE OF CALIFORN6wi WATER RESOURCES CONTROCBOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� : o <br /> �' COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 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 CLOSUREI rel <br /> 3 N <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACIL�ITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS_ ^1 , , �^1 //��j " NEAREST CROSS STREET ✓Barlo ir.Gwte Cl PARTNERSHIP ❑ STATE AGENCY <br /> A W A AC ❑ INDIVIDUAL <br /> 0 CCOOUNTY AG CY ❑ FEDERAL <br /> CITY NAME _/-` STATE ZIP CODE SITE PHONE a.WITH AREA CODE <br /> Twp. CA <br /> TYPE OF BUSINESS. ❑ 2 DIS IBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ � ❑ TRUST LANDS O ❑ N of HIS SITE / <br /> 1 GAS STATION FAflM SOTHEfl [AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME ' CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.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. 1p<ltl 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 /> COUNTYIN JURISDICTION N AGENCY N FACILITY IDN k of TANKS BI SITE <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME - PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LLOCATIONE CENSUS TRACT N SUP ISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI3 " aYES NO <br /> II In I <br /> PERMIT AMOUNT S HARDIE AMOUNT FEE CODE RECEIPT N BY: <br /> \1wITHIS 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 /> Y <br /> '-lo' DATA PROCESSING COPY r4 <br />