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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE " <br /> MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> IC <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> h Cape- ro <br /> ADDRESS j� <br /> NEAREST CROSS STREET ✓ i#I ❑ P/STNERERIP ❑ STAIEAGENCY <br /> G Q rid; YL Cl MMN ❑ LOCAL00 <br /> AGBIC! ❑ FEBF0.4L-AGBILY <br /> l...GL �� r'ry f �-- ❑ IrIBNIBUN ❑ cournAGDOX <br /> CIT'NAMESTATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID# y./ #of TANKS <br /> RESER <br /> ❑ I GASSTATION ❑3FARM �'�THER TRUSTYATION LANDSo ❑ /r/`r' N le. AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> pAVS NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> X11 a e esu (a ILL 9 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Sczm.e <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SSI P /ihuece re u Scvri, e <br /> MAILINGor STREETADORE ✓BLr/lt lntlicale ❑ PAflTNERSHIP ❑ STATE-AGENCY <br /> W4000RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> Q / ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME AO Cil\ STA ZIP CODE O PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a Owner <br /> MAILING or STREETADDL I/Box to indicate 11PARTNERSHIP Cl STATE-AGENCY <br /> 13CORPORATION Cl 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. ❑ II. NZ 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 If If of TANKS at SITE <br /> M 16ol <br /> CURRENT LOCAL A IENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> m <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVIISOOINDI TRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D 3. �'O "7 I YES NO � g� 00 <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# I I S <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OFFSITE INFORMATION ONLY. <br /> FORM A(3-2-88) S <br /> .... DATA PROCESSING COPY � _ <br />