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STATE OF CALIFORNN WATER RESOURCES CONTR BOARD <br /> FORM ' UNDERGROUND STORAGE TANK PROGRAM ="ter " o Z <br /> SIT� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION +� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �\FPe'N�o• <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PER OSED SITE I-+ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FA /SI NAME � CARE O A DRESS INFORMATION <br /> L A <br /> ADDRESS <br /> NEAREST OC(Of SCORPTA ❑ STATE AGENCY <br /> El CORPORATION El LOCALAGENCY [I FEDERAL AGENC <br /> Y <br /> ❑ INDIVIDUAL ❑ fAUNiVAGENCi <br /> CITU NAME "Ito /C STATCA IPC Z01 17E PHO ft WITH AREA COBS <br /> TYPE OF euSME55: ❑ 2 ISTRIBUTOR ❑4 PROCESSOR ✓Bax if INDIAN EPA ID p p of TANK'e <br /> RESERVATION or ❑ y AT THIS SITE01 <br /> ❑ 1 GASSTATION 3 FARM ❑ 5 OTHER ;TRUST LANDS �L/ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(RAST,FIRST) PHON p WITH AREA CODE DAYS'. NAM (LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N ITH AREA CODE NIGHTS Nk (LAST.FIRST) PHONE ' I H AREA CODE <br /> ac J <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> E Ch 0 ApDRESS.INFORMATION <br /> MAILING or ST ET DRE S ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> y aCO��iiPORATION ElLOCAL-AGENCYElFEDERAL-AGENCY <br /> -wolIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP COD HONE ,WITH AF7�Q CODE <br /> 5 !y C�j� <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATEAGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,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 0 AGENCY# FACILITY ID p #of TANKS at SITE <br /> mCID � v & :01 10100 IE <br /> CURRENT <br /> FACILITY IO p APPRO FY NAM �0 PHONE p WITH AREA CODE <br /> PERMIT APPROVAL DATE - PE EXPI ATION DATEUSTRACT# SUPERVISO�SRT_ICT CODE BUSINESSPSNFILED N DATE FFIEDIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p P'D`V 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(3-2-88) <br /> DATA PROCESSING COPY <br />