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STATE OF CALIFORMIX WATER RESOURCES CONTRCrGOARD (QIZO <br /> FORMA: UNDERGROUND STORAGE TANK PROGRAMSITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �O —4 <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) w CJI <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> LL-L-bi <br /> I <br /> !0lrNDMDU'1'0' <br /> ADDRESS NEAREST CROSS STREETBPvbfdi®V ❑ PpRRIERXIP ❑ yTp1E-pGE1N,y <br /> �` ❑ LOCAL MDAN ❑ RDUK-AGM <br /> ❑ COUMASSN9 <br /> CITY NAME STATE ZIP ODE SITE PHONE N,WITH AREA CODE <br /> CA LIS2gIbN Z01 7g1� <br /> TYPE OF BUSINESS: [D 3 DISTRIBUTOR ❑4 PROCESSOR ✓BOz#INDIAN EPA ID N <br /> ❑ 1 GASSTATION F-13 FARM E] 5 OTHER TRUSTYLANDS or El #of AT THIS SIHIS SI TE ' <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N 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 /> NAME CARE OF ADDRESS INFORMATION <br /> L LLD Fv<- 7•A - r <br /> MAILING o,STREET ADDREP. /� ✓ indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ' V D 1L �2 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> J INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME �O{M STAT ZIPCODE PHONE N,WITH AREA CODE <br /> ASzK <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ^ ^ CARE OF ADDRESS INFORMATION <br /> C I <br /> MAILING a,STREET ADDRESS ✓Box to indicate 11 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 /> 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. Z 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&SIGNATURE) DATE <br /> l <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURUVICTION# AGENCY# CILITY ID# #of TANKS at SITE <br /> END lb= <br /> CURRENT AL AGENCY FACILITY IDN 1 APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCAT16 CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <�p <br /> l/J``/Y-�, a� q ( YES Lj NO ( — 1L�— 1`�(. <br /> CHECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 /> 1 /FORM A(32 861 <br /> LDATA PROCESSING COPY <br />