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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM `AP: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION1d <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•oa�'" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION IV7 PERMANENTLY CLOSED SITE I"B' <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) 23 <br /> FACILITY/SITE NAME I CARE Of ADDRESS IN RMATION <br /> T F rn Roti UC <br /> ADDRESS �� NEAREST CROSS STREET J41_7111 <br /> NMink ❑ PMTNERWIP ❑ STATE-AGENCY <br /> CfmPOAAiION 0 LOCAL AGENCY 0 FECERnL AGENCY <br /> HA SS/H6/✓ ❑ INOMOIIAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZI CODE SITE PHONE N.WITH AREA CODE <br /> Ta CA S 6 <br /> TYPE OF BUSINESS. p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ I GAS STATION ❑ 9 FARM 5 OTHER TRUSTYLANDS or <br /> ❑ ��/ A THIS S1i <br /> AT THIS SI <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS:UNAME(LAST,Fl ST) PHONE a WITH AREA CODE DAYS: yAy�E UNK(LAST.FIRST) PHONE a WITH AREA CODE <br /> NCe -`y <br /> NIGHTS NAME(LAST,FIRS11 PHO a WITH AREA CODE NIGHTS: NAME LAST,FIRST) PHONE a WITH AREA CODE <br /> (J crA. 85-6 N <br /> IL PROPERTY OWNER INFORMATION &AbDRESS — (MUST BE COMPLETED) <br /> Ni CAR FADDRESSINFORMA17 <br /> NC Pv <br /> P <br /> MAILIIgG or STREWDDRESS ✓ lox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> .rCj. q -9 CORPORATION 0 LOCAL-AGENCY ❑ FEDERALAGENCY <br /> P/ �✓ 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY N htE STAT ZI�355 PHONE#,WITH AREA CODE <br /> M P CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S114Hr AS <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN 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. ❑ I. ❑ 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 /> COUNTgY R JURISDICTION R AGENCY A FACILITY IDA • N o1 TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY 10 A APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROV DN 7T <br /> ATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTNACCTTN SUPERVISOR-DISTRICT CODE BUSINES,PUN FILED No <br /> ❑ DATE FIL 0 <br /> s O `I <br /> CHECKF 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 ONIs <br /> ` I FORMA(3-2-88) <br /> DATA PROCESSING COPY <br /> 1116 __� <br />