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STATE OF CALIFORKF <br /> WATER RESOURCES CONT BOARD <br /> FORMA.. <br /> s f <br /> UNDERGROUND STORAGE TANK PROGRAM �e <br /> Sl1' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w, .. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 'I', R <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Z17 PERMAIINN�E TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE s{,� <br /> 1© <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACT /AFACg/SJVA CARfi0 ADDRE IrMATI <br /> q _ / E TCR S RE ✓�elloilNicale ❑ PARTNERSHIP STATE AGENCY <br /> {G COAPGRAPGN ❑ LGGLAGENCf ❑ FENRAL AGENCY <br /> ILIA 0 INDIVIDUAL 0 CDUNTl AGENCY <br /> CITY NAME STATE ZI CODE SIT ONE a, ITH AR CODE <br /> p l CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR F-14 PROCESSOR ✓Be.A INDIAN EPA ID 4RESE #of TANK's <br /> ❑ ❑ TRUST LANDS ATION or ❑ E' <br /> 1 GAS STATION 3 FARM 6 0THEfl AT THIS TANK's <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE it WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NyAE T C E FADD5 FOR TION <br /> /V( <br /> M G or ST DR SS /© Box to indicate 0 PARTNERSHIP 0 STAT GENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEOER L-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> NAME STATE H ITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) S S <br /> NAM F ADCSOFO�yAAT10N <br /> NG or ST ADDR SS L• ✓6 Box to indicate Y 0 PARTNERSHIP 0 STAT AGENCY <br /> J/� /L/^� ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> �� \ Q U ❑ INDIVIDUAL ❑ COUN 'ENCY <br /> NAME ST Z 0 E NEp WIT REA CODE <br /> if.t>tit l5 b ►. <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK DNE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. 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 If #of TANKS at SITE <br /> M I I I t ( © 10 b b <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> �1_04 0 <br /> MIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE C N9AI8 TRAC�,T# SUPE •DISTRICT CODE BUSINESS PLAN FILED ❑ T FI <br /> /VI t, S O,I If/� YES NO <br /> CHECK Ir PERMIT AMOUNT SDRC ARG AMOUNT FEE CODE RECEIPT# B <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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY • <br />