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STATE OF CALIFORNT'b WATER RESOURCES CONTROL BOARD "'' <br /> FORMA!: UNDERGROUND STORAGE TANK PROGRAM =� _ �o <br /> SITE L FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-a <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CO <br /> A <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> V12, L'. 4ZOST8141 <br /> ADDRESS NEAREST CROSS STREET ✓Bmp,tlole ❑ PAFff*FW Cl STATE AGENCY <br /> ❑/ GOPOR1TI0N 11LOGLAGENCY 11FEDEPNAGENLY 11INDNIDJAL ❑ CWNTY.AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> �S CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ APROCESSOR ✓Box if INDIAN EPA ID Al <br /> I GAS STATION <br /> ❑ [:]3 FARM ❑ S OTHER RESERVATION or ❑ E <br /> Mol TANK'N <br /> AT THIS SIT <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 Al WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓So.to imicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ 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 STREET ADDRESS ✓Bax loinUicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <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. ❑ 11. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANO CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY Y JURISDICTION K AGENCY M FACILITY ID R B of TANKS at SITE <br /> o3 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTI SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE PLED <br /> YES NO �'2 <br /> CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM Y: <br /> j THIS FORM MUST BE ACCOMPANIED BY AT LEAST IIN OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNI FSS THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORM A(3LFBB) <br /> DATA PROCESSING COPY <br /> I <br />