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STATE OF CALIFORNIO WATER RESOURCES CONTR BOARD <br /> FORMA": UNDERGROUND STORAGE TANK PROGRAM �o <br /> Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION N ;1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 67 <br /> 07 <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) p <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Box to Ydirate ❑ PARTNERSHIP ClSTATE AGENCY <br /> __ ❑ TION 11 LOCAL AGENCY 11 FEDERAL <br /> /-z:) �f; INGNIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE A.WITH AREA CODE <br /> ,_DO/ CA 1�s2 .ZII <br /> TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bout INDIAN EPA ID 4 p of TANK's <br /> RESE <br /> ❑ 1 GAS STATION ❑ 3 FARM THE <br /> R TRUSTYLANDS or [D AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> .705 - G3 <br /> NIGHTS'. NAME(LAST, (RST) PHONE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,ST/R'7EET ADDRESS� / ✓Box m indicate ❑ PARTNERSHIP ❑STATE AGENCY <br /> /� 14 L/�•-Q ❑ CO NIDUgLRATION D LOCAL AGENCY❑ COUNTY AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME / STATE ZIP CODE PHONE p,WITH AREA CODE <br /> /—o IDI �s� 6� s63� <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING o,STREET ADDRESS I/Box W indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ If. EeIII. ❑ <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 p JURISDICTION p AGENCY k F IDN #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID - APPROVED BY NA PHONE p WITH AREA CODE <br /> PERMIT NU BE PERMIT TE PERMIT EXPIRATION DATE <br /> LOCATION qCODE CENSUSTTRACT p SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> CHEC 02— PERT AMOUNT SURCHARGE AM/NT FEE CODE YES ❑RECEIPTNO ❑ BY: <br /> THIS <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 ON <br /> FORM A(3-2-88) <br /> • DATA PROCESSING COPY <br />