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Se�'��w,"•he <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROOARD V _, <br /> FORMW: 0 1 z <br /> UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE �fi l FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> ry I OPiP <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE — <br /> MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWALPERMIT V5 CHANGE OF INFORMATION 7 PERMANE L LO <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE /,� ✓/ ("n <br /> Go <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) tG <br /> FACILITY/SITE NAME CAREOFADD ESSINFORMATION <br /> ADDRESS /J NEAREST R SS STREET ✓H oiMicate ❑ PARTNERSHIP Cl STATE AGENCY <br /> 3a i 0 f,� Y (-w.- ('/I B fNDWIDU TION ❑ LOCAL. "g,GY ❑ FEDEAAI AGENCY <br /> Cl INDNIpDAE ❑ CDI1NttAGENCY <br /> CITY NAME. 'F STATE ZIP CODE SITE P ONE N,WITH AREA CODE <br /> zerr^ CA - 0 3 0 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID X #of TANK'X <br /> RESERVATION Or ❑ AT THIS SITE I <br /> 1 GASSTATION [:] 3 FARM 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE M WITH AREA CODE OAVS. NAE,�E(LAST,FIRST) PHON)/1 p WITH AREA CODE <br /> DAYSNAME(LAST,FIRST): N7 <br /> /1 <br /> NAME(LA ,FIRST) A <br /> PHONE p WITH AREA CODE NIGHTS'. AME(LAST,FIRST) PHON 'bp WITH AREA CODE <br /> NIGHTS: <br /> ;y- Flo � <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE f ADDRESS INFORMATION <br /> NA <br /> MAILIN STREET DRESS ✓ ox tPORA IO ❑ PARTNERSHIP ❑ STATE AGENCY <br /> F 4�,, /J b�a IN ZIP <br /> Fl COU NTV AGENCY FEDERAL-AGENCY <br /> T <br /> CITY NAME �I lI•l I . / STAY^ ZIP COD PHONE WITH AREA OD-V V✓ <br /> Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> l�Il <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET AO ESS y/f,,`.'x to indicate ❑ PARTNERSHIP Cl STATEAGENCY <br /> D <br /> Tr CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE I PHONE ,WITH AREA CODE <br /> CITYN E � <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS !� 1 <br /> CHECK ONE(f)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED 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 p wGENCY k FACILITY ID# #of TANKS at SITE <br /> o0 <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> APPROVED ll NAM PHONE#WITH AREA CODE <br /> cAL,pi1,3 <br /> PERMIT NUMBER PER MIT APPROVAL DATE PERMIT EAVIKA I ION DATE p <br /> /L <br /> LOCATION CODE CENSUS TRACT At SUPERVISOR-DISTRICT CODE BUSINESPUN <br /> SNFILED N i' DATE FILED <br /> r O `„IKIXJ JYE'Gfi- <br /> CNEC N PERMIT AMOEE C <br /> UNT SURCHARGE AMOUNT FODE RECEIPTX BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE TANK PERMIT FORM 'B'APPLICATIONM, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-813) S <br /> DATA PROCESSING COPY <br />