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ST4TE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '"" ` <br /> FAM IAP' UNDERGROUND STORAGE TANK PROGRAM <br /> ITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Uz�i-vERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 000 <br /> FACILITY/SITE qNAME CARE OF ADDRESS INF ATION i <br /> ADDRESS NEAREST/C_AO STREETWEl_ .LEw�iMule PA EMIP ❑ STATE-AGEND <br /> 11011 L 0D❑0�INDWIDIIk O AGENGN ❑ FEL4 ILAGENY <br /> CITY NAME /T� STATE <br /> CA 50 G l��SITE E `/fET� EA�CODE <br /> 3� <br /> TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑ 4PROCESSOR ✓Boz it INDIAN EPA ID Y S NOfTA,NKs <br /> ❑ I GAS STATION ❑ 3 FARM OTHER RESERVATION or ❑ UK pT THIS SITE <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> pN d - -355 Gf <br /> NIGHTS: NAME(LAAT,FIRST) PHONE 4 WITH AREA CODE N�CifiT$.�VE(LAST,FIRST) PHONE If WITH AREA CODE <br /> ab '0Q"- Z3 /�I/K <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> bBUe--, <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e s ba v�e,- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,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. it. ❑ 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 K JURISDICTION K AGENCY R FACILITY ID Y N of TANKS at SITE <br /> ml 10a1 11,5 -e-�- <br /> CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE <br /> N <br /> PERMIT NUMBER PERMIT APPROVAL OkTE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS/S N FILED NG ❑ OAT,/,L <br /> Fz D <br /> CHECK• 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 <br /> FORMA(3-2-88) <br /> �� DATA PROCESSING COPY �( <br />