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i <br /> STATE OF CALIFORNM WATER RESOURCES CONTROL BOARD <br /> FORM I <br /> i. <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "'F�.ow�"� <br /> MARK ONLY ❑ I NEWPMMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE )—► <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / ^J <br /> a <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS- (MUST BE COMPLETED) CO <br /> FACILITY/SITE NAME CTI <br /> A d CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓8monsom, 0 PMTNUCHIP 0 STATEAGENEY <br /> -0 0 CORPORATION 0 LOCAL AGENCY 0 FENEAAIAGENCY <br /> 0 INDAWAL 0 COIATYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> L CA Gj <br /> TYPE Of BUSINESS: ❑ 2 DISTRIBUTOR ❑ /PROCESSOR ✓Box if INDIAN EPA 10 p <br /> ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER I TRUST LANDSRESERVATION of ❑ Not TANK's <br /> AT 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 Wt TH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION 8 ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION 8 ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> Cl CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> i <br /> CHECK ONE(1)BOX 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 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION R AGENCY K FACILITY ID R It of TANKS at SITE <br /> ,2 3 <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE At WITH AREA CODE <br /> Xy <br /> PERMIT NUMBER ` PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES [] NO � A.20 <br /> CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If B . <br /> Wall <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 ONLY. <br /> '\ FORMA(3-2-SS)1 C <br /> �� I DATA PROCESSING COPY <br />