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STATE OF CALIFORNIP WATER RESOURCES CONTROSOARD <br /> FORM NA': UNDERGROUND STORAGE TANK PROGRAM = � a <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7,,Y-ER� LY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE , <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME 60/&P CARE OF ADDRESS INFORMATION <br /> A /v\#:-gi&x� NSI MIS <br /> NEAREST CROSS STREETa7b <br /> RK) TOD PABINEMEN DFEDESTATR L AGENENCY <br /> ADDRESS � j � APOMTON ❑ LOCAL AGFNGY ❑ FEOEPALAGENf,Y <br /> Mac &'Y)ti p- IDUAL D couNTYAGENaCTY NAME STATE ZIP CSITE PHONE N.WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a %of TANK'N !l <br /> RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP D STATEAGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY C FEDERAL-AGENCY <br /> ❑ INDIVIDUAL D COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS <br /> -/Box to indicate Cl PARTNERSHIP D STATE-AGENCY <br /> Cl CORPORATION D LOCAL-AGENCY C FEDERAL-AGENCY <br /> D INDIVIDUAL D COUNTYAGENCY <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. ❑ it. ❑ 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% %of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY IDNS APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DI TRICT CODE BUSINESS PLAN FILED 722] <br /> CHECKS 3 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE YES ❑RECEIPTING ❑ <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 /> RM A(3-2-88) 0 0 <br /> V <br />