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or- <br /> STATE OF CALIFORNI0 WATER RESOURCES CONTRJNIOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM .{ <br /> m . <br /> SITE 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 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITYISITE NAME CARE OF ADDRESS INFORMATION <br /> 3-Oha2 S• pane--o <br /> ADDRESS 1` NEAREST CROSS STREET ✓Bw0Not ❑ PARTNERSHIP ❑ STATEAGENIX <br /> i r a 35 5. V Q erC 1:1 �IDINL13 � 11ICO MIKAGENp ❑ FEDEMI AGENq <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> £s Cal WL CA ?-v <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ d PROCESSOR REBox it INDI <br /> SERVATION N EPA ID N 0 of TANK'a <br /> ❑ I GAS STATION FARM ❑ BOTHEfl TRUST LANDS ❑ AT THIS SITE �. <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> pip ' q 838- 75 7 <br /> NIGHTS'. NAME ILA .FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME SU Iv, s lM l�,/o CARE OF ADDRESS INFORMATION <br /> � I <br /> MAILING or STREET ADDRESS <br /> I I �✓ ✓Box to indicate ❑ PARTNERSHIP 13 STATEAGENCYGENCY <br /> ION 0 LOCAL-AGENCYFEDERAL AGENCY Y/o,y1m ❑ INDIVIDUAL 13 COUNTY-AGENCY <br /> CITY NAME STATZIPCOD� PHOEpWITH AREA CODE <br /> 6fn C/ _ <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5d" CLS CL b o ue <br /> MAILING or STREET ADDRESS ✓sox toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABO IN ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION M AGENCY k FACILITY ID R R of TANKS at SITE " <br /> 6) 1 0 2-1,,?- 1 o 1 o 1 1 V I d 16 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERV)SOWDISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 1, YES NO <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT R BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) • <br /> v g�� � U1��lpy- u • <br />