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STATE OF CALIFORNIX WATER RESOURCESCONTROLBOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM = � o z <br /> S FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m< - to <br /> C9lIFORNIP <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ID4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I"a <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) fQ+ <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ro w . he�v+e f` i y" <br /> ADDRESS (� NEAREST CROSS STREET ✓9or.to idreb ❑ PARME95HIP ❑ SfAiF-AGBKY <br /> e I C ❑ wN�a TION ❑ LM& GOD ❑ FmRw AGOV <br /> off ( T �YBN�DGAL ❑ WUNIY#GBILY <br /> CITY NAME p STATE ZIP ODE TE PHO# p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑!,DqMIBIJTOR ❑4 PROCESSOR ✓Box it INDIAN EPA 10 N ROITANICN <br /> RESERVATION or ATTHIBSITE <br /> ❑ t GASSTATION 3 FARM ❑S OTHER TRUST LANDS 1:3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: AME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> i S � 4il <br /> NIGHTSNAME(LAST.FIRST) PHONE HH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> II. 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 ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS JBox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 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 /> COUNTY N JURISDICTION R AGENCY40 FACILITY ID R R of TANKS N SITE <br /> PI = = rojolZ47RW Eoliblokl <br /> CURRENT LO�CYFACILIT'ID MI APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION ODE CENSUS TRACT# SUPERVISOR-01 CT CODE BUSINESS PLAN FILED DATE LED <br /> a 3 a a YES ❑ NO a <br /> CHECK# 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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />