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STATE OF CALIFORNI WATe!; RESOURCES CONTR( 30ARD <br /> FORM °a°: <br /> �� UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> r <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'+�•aen`% <br /> MARK ONLY ❑ 1 NEW PERMIT [::] 3 RENEWAL PERMIT 1:1 5 CHANGE OF INFORMATION EVPERMANLNTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT E] 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE <br /> .7 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) F/4 <br /> FACILITY/SCoITE NAME CARE OF ADDRESS INFORMATION <br /> m <br /> AD NEAREST NEAREST CROSS STREET ✓g�eevMMcae ❑ PMTNEREHF ❑ STATE AGENCY IV <br /> 1 L�C04011ATO Cl LOCAL-AGENCY ❑ FEGERALAGENLY <br /> 5 ❑ INDMDUAL ❑ CgMTY AGENC <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA q 0 <br /> TYPE OF BUSINESS. [S2TDISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> 1 GAS STATION ❑ 3 FARM 5 OTHER RESERVATION or N of TANX'N <br /> ot-�E ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST FIRST) PHONE#WITH AREA CODE <br /> L_ _ ZOE') 7041 <br /> NIGHTS- NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> EAMIF <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> CO LSE <br /> MAILING or STREET ADDRESS ✓!moo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> —e0 BcJ Lar CORPORATION 11LOCAL-AGENCY 13FEDERAL-AGENCY <br /> /( ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> �( 852-01 - <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAM ry(�/�` CARE OF ADDRESS INFORMATION <br /> E1Cl..T- <br /> MAILING or STREET ADDRESS p� ✓ -to indicate Ll PARTNERSHIP E3STATE-AGENCY <br /> X ass Be"CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> C - <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. ED it. K 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AGENCY N FACILITY ID N N of TANKS at SITE <br /> O <br /> CU RENT LOCAL AGENC FACILITY IDN APPR VIED BY NAME p PHONE N WITH AREA CODE <br /> OL iC- 8 —7 0 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EX (RATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> 2 3 Q Wy YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> t DATA PROCESSING COPY <br />