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STATE OF CALIFORNIA- WATER RESOURCES CONTROL BOARD '` °�• " <br /> 1 1 <br /> RM A: UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERM"NENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE �J <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACT ITY/SITE NA D RTb FVow< h G CARE OF ADDRESS INFORMATION <br /> ADDRESS / / `6^/ NEAREST CROSS STREET ✓ ❑ PANMER➢IIP ❑ STpiEAGENLY <br /> ✓ TION ❑ l0(X VANC( D 110EK-AGDO <br /> D INDM M D CWNIYAGENCY <br /> CITY NAMEST ZIP CODE SITE PHONE N.WITH AREA CODE <br /> S C CA a _� c-7- 4 0 5, <br /> TYPE OF BUSINESS: ❑ 2 DISTRI OR ❑4 PROCESSOR ✓Box if INDIAN EPA IDN N of TANKY <br /> ❑ 1 GAS STATION ARU ❑ 5 OTHER TRUSTYLANDS OATION r ❑ IAT THIS SITE <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 /> L a 9-3 &6,5 <br /> NI HTS 1 NAME(LAST.FIRST( PHONE N WITH XREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS I/Box to Ifteate ❑ PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> D INDIVIDUAL D 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 ✓Box to ln0icate ❑ PARTNERSHIP D STATE-AGENCY ' <br /> ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOY INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 111. ❑ <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 /> COUNTYJI JURISDICTION N AGENCY N R of TANKS of SITE <br /> CURRENT LOCAL AGENCY FACILITY IO N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER OVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N� SUPERV 8011-0ISTRICT CODE BUSINESS PLAN FILED DATE FI D J� <br /> p�3 YES ❑ HOE] 7 T <br /> CHE N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> IS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM •S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLYQ <br /> FOR A(3-2-N) ✓// <br />