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STATE OF CALIFORNif WATER RESOURCES CONTROL BOARD ?`' f <br /> Vis. <br /> FORMA': ����.� , ��; <br /> UNDERGROUND STORAGE TANK PROGRAM , �� wo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION "� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `^��.oaN�P <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN ED SITE PV <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) p <br /> FACILITY/ /N�AM�E CARE OF DDREES INFORMATION <br /> Vvf, <br /> ADDRESS � ) NEAREST CROS STREET ✓Roe to indiWl9 ❑ PARTNERSHIP ❑ STATEAGENCY <br /> foo k 1 Li. � Nl`lUAA➢ON 11 COUNTY AGENCY FEDERALAGENCY <br /> CITY NAME STATCO <br /> f7 �� AREA <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 OCESSOR -/Emit INDIAN EPA Ip ftESE7 <br /> It of TNK's <br /> F__] T GASSTATION F-13 FARM 5 OTHER TRUSRYLANOS ATION or ❑ CAC-0001604M AT HAS SITE 4i <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE q WI AREA CODE DAYS ME(LAST,FIRST) PHON q ITH AREA CODE <br /> A S � f � <br /> NIGHTS: NAME(LAST,FIRST) PHONEk HAREA CODE NIGHT AVE(LAST FIRST) PHONE�IWITH AREA CODE <br /> 4 �x aAa d( KAI <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGor 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 N.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM�ACARE OF ADDRESS INFORMATION <br /> V <br /> MAILING o,STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY`NAME BTATE 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. ❑ 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# JURISDICTION# AGENCY# FACILITY ID Is #of TANKS at SITE <br /> mc) 0 � a ") I Ii <br /> CURRENT LOCALAGE CY FACILITY ID# APPROVED BY NA PHONE#WITH AREA CODE <br /> zoAocza3 1416 <br /> PERMIT NUMBER PERMIT APPROVAL DATE MIT 1EXPIRATION DATE <br /> LOC CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED �—,/ DATE FILED 7 6 <br /> 2� YES ❑ NO 2 <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASTfR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNSS THIS IS A CHANGE OF SITE INFORMATION ONL t <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />