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q 14A,# 233 -060-01 <br /> �/ <br /> STATE OF CALIFORNIA'" WATER RESOURCES CONTROL*OARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o o <br /> C COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSUREff Fil 00 <br /> N <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> IV <br /> FACILITY/SITE NAME I ' CARE OF ADDRESS INFORMATION <br /> l QN <br /> ADDRESS NEAREST CROSS STREET ✓ 11PARTNEOW ❑ STATEAGF#LY <br /> fAMORATIBN ❑ bXMDILY ❑ PECEMLAGDO <br /> S//c ❑ INDNIOIIN ❑ CU.W1Y-AGE4CY <br /> CITY NAME STATE ZIP CODE SITE PHONE 9,WITH AREA CODE <br /> 2//C CA 537& r2o,0 t35A&l <br /> TYPE OF NESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID If <br /> RESERVATION or N of TANICN <br /> 1 GAS STATION ❑ 3FARM ❑5OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: E(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST, ST PONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r-Fs7;m/A <br /> MAILING or STREET ADDRESS ✓Box to irMicate Rr PARTNERSHIP ❑ STATE-AGENCY <br /> ❑l CORPORATION 1:1 LOCAL-AGENCY 13FEDERAL-AGENCY11 INDIVIDUAL ❑ COUNTY-AGEN <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWN6 INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREE IAOORESS ✓Box ind <br /> ica <br /> te ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �� ) O PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> �3 (il/ NDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEZIP CODE P ONE# WITH AREA CODE <br /> EA- 953 7� a -31b <br /> IV. LEGAL NOTIFICATIO AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: 1. 1. El III Pr <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# JURISDICTION# AGENCY# FACILITY IDN Nof TANKS BI SITE <br /> 01( 35 171 IL101010_ <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> S <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS 7SUPERV180R-DIS CODE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> CHECXN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 INFORMATION ONLY__ <br /> FORM A(3-2-811) <br /> `F DATA PROCESSING COPY ""' <br />