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STATE OF CALIFORNIN WATER RESOURCES CONTRdCBOARD 0• <br /> FORM 'AI: UNDERGROUND STORAGE TANK PROGRAM <br /> m A� <br /> io <br /> SIT9 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> A COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 15 CHANGE OF INFORMATION PERMANENT Y CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/ ITE NAME T CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STRE T ✓8mlorticeN 0 PARfNERS4P 0 STATE AGENCY <br /> E 0 COWWTIGN 0 LDCALAGENCY 0 PEDERLLAWO <br /> C � 'Au 0 NUMDurL 0 CGWM AGENCY <br /> CITY NAME STATE CODE SITE PHONE N.WITH AREA CODE <br /> C� Q CA <br /> TYPE OF.USI ESS: ❑2 DI OR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> A of TANKI <br /> RESERVATION or ❑ �Q'vl.Q, AT THIS SITE <br /> ❑ 1 GAS STATION 3 TARN ❑ 8 OTHER TRUST LANDS <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 /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl 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 /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or ST ET ADDRESS ✓Box 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 N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ADOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. I. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDG16S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUTT��IINTTYY#���II JURISDICTION S AGENCY k FACILITY ID R R of TANKS N SITE <br /> O <br /> CURRENT LOCAL AO ILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE <br /> r S to <br /> PERMIT MBE MIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOWDISTRICT CODE BUSINESS PLAN FILED DATE FILED fj'JJ <br /> �l 3, 01 <br /> -3 YES NO � <br /> CHE P PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N <br /> IS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL <br /> A(3-2-88) <br /> l / <br />