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STATE OF CALIFORNI)e WATER RESOURCESCONTRO'E400ARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM s i <br /> SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION >'. g <br /> Ci COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT Lff5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> I <br /> FACILITY/SITE NAME CARE OF DDRESS INF ATION <br /> I A•A N C1.C. <br /> ADDRESS NEAREST CROSS STREET ✓Saiwvdmie ❑ PMTMDBIIP ❑ STATE AGENCY <br /> ❑ 00MMTI0N ❑ LOGL-AMO ❑ FMWAGDO <br /> (./ ❑ INDMODa ❑ DuupnaBBla ' <br /> CITY NAME _ ` STATE 21P ODE_ SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: 2DISTRIBUTOR VROCESSOR ✓BozK INDIAN EPA IDa <br /> RESERVATION or AT <br /> HIS SITE <br /> 0 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS- 0 AT THIS BTE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> l Ger 209 eL <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> I <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> I N lca A.u�rc <br /> MAILING or STREET ADDRESS A' ✓Box to indicate El PARTNERSHIP 11STATE-AGENCY <br /> 11 LOCAL-AGENCY <br /> /_/�M� 11NDIIVIDUAL ON ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAJE STATE ZIP CODE PHONE p.WITH AREA CODE <br /> C/ iN � 4 S O <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,v RI Cu <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> O ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE N,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: L 0 I. 0 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 R JURISDICTION M AGENCY k FACILITY ID N S of TANKS N SITE <br /> i <br /> d o 6 O g1010101 <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE p WITH AREA CODE <br /> 2 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D <br /> 2.3, 60 %ZSR YES NO 1 p <br /> CHECK PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Ji 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 ONLY.�- <br /> FORM A(3-2-SS) J <br /> DATA PROCESSING COPY Yw <br />