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STATE OF CALIFORNIAWATER RESOURCES CONTROL BOARD P*`=`:" :s <br /> FORM `AUC <br /> � <br /> UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> A� <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Pvq CHANGE OF INFORMATION PERMA OSED SITE SV <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE cm <br /> CT <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> FACILI /SITE AME �A/�, CARE O ADDRESS INFORMATION <br /> 6463 • A114- <br /> AGGR SS ) /7 NEAR CROSS STREET ✓BF,to inQnele PARTNERSHIP E STATE AGENCY <br /> / / / I� N,- ❑ CORPORATION ❑ LOCAL AGENCY ElFEDERAL AGENCY <br /> VV /��T ❑ INDiNDUAL ❑ COUNTY-AGENCY <br /> CITU ele 5 ATCA Z � SI0PH N3,WITH AREA CODE <br /> TYPE OF BUSINESS ❑ p DI RIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a _ 68 <br /> RESERVATION or / q #of TANK's <br /> ❑ 1 GASSTATION FARM ❑ 5 OTHER TRUST LANDS ❑ /v T' AT THIS SITE QO <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: AM T,FIRST) F jNEITH AREA CODE DAYS' N E(LAST,FIRST) PH p ITH AREA CODE <br /> C ` J � l <br /> NIGHTS'. NAME(L@IGCTiPHON pWOR AREA CODE NIGHT �ME(LAST,FIRST) PHON�p ITH AREA CODE <br /> ✓\74 �. dL <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> UA <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION E LOCALAGENCYE FEDERAL AGENCY <br /> ❑ INDIVIDUAL E COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME_ CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP E STATE AGENCY <br /> E CORPORATION ❑ LOCALAGENCYE FEDERAL-AGENCY <br /> E INDIVIDUAL E COUNTYAGENCY <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. 0� 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION IF AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APP OVED BY PHONE#WITH AREA CODE <br /> K / <br /> PERMIT NUMBER PERMIT APPROVAL DATE FIERIMITE0111311VIDIONbATE <br /> LOCATI N CODE CENSUS TRACT#7 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED V J <br /> J YES NO A*_ l �/ 1 <br /> /J <br /> 11 <br /> CHIECKV PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMI)i BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM AI 88) 116 <br /> J` <br /> C) W 0l/"1",� DATA PROCESSING COPY <br />