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os <br /> STATE OF CALIFORNI.0 WATER RESOURCES CONTROL 0ARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM y �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 10 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> IV <br /> ADDRESS �C NEAREST CROSS STREET ✓Bar to iRGcan ❑ PARTNERSHIP ❑ STATE AGENCY 00 <br /> 13 INDIVIDUAL <br /> 13 AG 13 FEDERAL <br /> ENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> CA S X09 - 33 <br /> TYPE OF BUSINESS: 2DISTRIBUTOR ❑ 4PROCE ✓Box it INDIAN EPA ID # #of TANK's <br /> ❑ 1 GASSTATION ❑3 FARM ER TRUSTMLANDS ATION ar ❑ , <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WH AREA CODE <br /> o Z F�33 e 1 ITT 3 <br /> NIGHTS: NAME(LAST,FIRST NE#WITH AREA CODE NIGHTS'. NAME III FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME / ARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCY11 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITYN STATEZIP CODE PHONE#,WITH AREA CODE <br /> S33 <br /> 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS 10 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. y 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# JURISDICTION# AGENCY# FACILITY ID# #o1 TANKS at SITE <br /> D / 1= I OU <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> dom <br /> LOCATION CODE LENS RACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ D iltr--a <br /> 3 YES NO <br /> CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM BY APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORMA(3-2-88) J( <br /> DATA PROCESSING COPY <br />