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STATE OF CALIFORNIA WATER RESOURCES CONT BOARD ., <br /> FORM IA': UNDERGROUND STORAGE TANK PROGRAM w <br /> SITE �+ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION }fir <br /> V COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r' X <br /> I. FACILITY/SITE INFORMATION 81 ADDRESS — (MUST BE COMPLETED) C.V <br /> FACILITY/SI E NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS I NEAREST CROSS FEET ✓Box loiigI ❑ PARTNERSHIP ❑ STATE AGEND' <br /> p� (q a ❑ CORPORATION ❑ LOGALAGENCY ❑ FEDEMLAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTKAGEND <br /> CITY NA STATE ZIP CODE SITE PHONE p,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID N(� ���/'��^�/ <br /> If of TANK' <br /> ❑ I GAS STATION 'X 3 FARM ❑ 5OTHER TRUSRESETLANDS <br /> ATION or ❑ �J�CL/l.�/S; (O ? AT THIS SITE Ohe <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(LAST,FIR T) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE NWITH AREA CODE <br /> NIGHT NAME(LAS IRST) '` PHONE N WITH AREA CODE NIGHTS'. NAME(LAST FIRST) PHONE N WITH AREA CODE <br /> \J -YosS <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME N,T . <br /> CARE OF ADDRESS INFORMATION <br /> h fan <br /> MAILING or STREET ADDRES ✓ ox to indicate ❑ PARTNERSHIP CISTATE-AGENCY <br /> ECORPORATION 11 o. <br /> ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP C DE PHONE ,WITH AREA CODE <br /> �n 3 999-3011 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME k <br /> CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS 1✓'Box to indicate ❑ PARTNERSHIP 11STATE-AGENCY$ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAM STATF- 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: 1. ❑ II. 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APP NT'S NAME(PRIN 851GNATURE) DATE <br /> � a <br /> LOCAL AGENCY USE ONLY <br /> I�II� CZZOOU TY#NTTY k JURISDICTION 8 AGENCY N FACILITY ID R N of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVE <br /> CODE <br /> D BY NAME PHONE N WITH AREA CODE <br /> tic 2 I <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ��]-)-\' <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT BUSINESS PLAN FILED DATE FILED <br /> 0 3a0 YES NO 1�16 !Jd <br /> CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY; l /^ <br /> V/1 <br /> THIS FORM MUST HE ACCOMPANIED BY AT LEAST <br /> �FORMA(3-2-813) (1 ^ MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> /�� C <br /> 1� DATA PROCESSING COPY <br />