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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION Z <br /> and/or PERMIT APPLICATION m <br /> Ro j <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE `+crranr.,r <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 LOSER SITE IJ <br /> ONE ITEM ❑p INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE / -4 <br /> 519 / CA <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) 00 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STRE ny/ w raR 0 PAAII♦E W 0 VATE.AGS0 <br /> INDW <br /> o ❑ EGW A EnCITY NAME ZIP CODESITE PHONE#,WITH AREA CODE <br /> CA 5.202. 09 —23t/ <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ ROCESSOR ✓Box#INDIAN EPA ID <br /> 3 FARM OV5 Oa <br /> ❑ 1 GAS STATION THER RESERVATION or - F of TANK'. <br /> ❑ lCJ TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(IAST, IRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> ve - -. ?tN <br /> NIGHTS: N ME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NA (LAST,FIRST) PHONE#WITH AREA CODE <br /> ,• /T 207-y _ 225- 4lK7 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM �AW �+ �l CARE OF ADDRESS INFORMATION <br /> /.� <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Me <br /> us <br /> MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D INDIVIDUAL 0 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 WNICH ADM ADDRESS SHOULD MUSED 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# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> Oma / O151 1 Ovo0 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 3. b YES NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2A0) <br /> DATA PROCESSING COPY <br />