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STATE OF CALIFORWIpr WATER RESOURCESCONMrirSOARD ':�:;?`` <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM �o z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o Io <br /> COMPLETE THIS FORM FOR EACi! <br /> FACILITY/SITE �""�"=�� <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE SED SITE FJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE l <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ul <br /> N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Daww•N PO J(,L :z C"e5 <br /> ADDRESS '+- _ NEAREST CROSS STREET ✓Bmlovgirale 0 PARTNERSHIP D STATE413DO <br /> 33 2 T O GOWMTIION DO U)In cE c D 090.-ATEKLY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> EScu�ON CA 320 - 3 '45i9R <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ C Box if INDIAN M PROCESSOR RESERVATION Or EPA ID <br /> Of TANMN <br /> ❑ 1 GAS STATION E] 3 FARM E] 5 OTHER RESERVATION <br /> ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) '. <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS'. NAME(I-AST,FIRST) PHONE N WITH AREA CODE <br /> va -g 573 <br /> NIGHTS: NAME(LA90r.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 /> NAMECARE OF ADDRESS INFORMATION <br /> "V N <br /> MAILING or STREET ADDRESS ✓Box toindicate D PARTNERSHIP D STATE-AGENCY <br /> /J D CORPORATION D LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> G N Ori- D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> E'sco 16" CA 1S3 0 Z sf` -9so <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRE ✓Box to indicate D PARTNERSHIP ❑ STATE-AGENCY <br /> D CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY <br /> D INDIVIDUAL 0 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. 111.❑ <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 M FACILITY ID N k of TANKS at SITE <br /> 3 `l = = I I 1,;?- 11 1 :5 / <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> Sd e2 ' <br /> PERYR NU R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL D <br /> YES ❑ NO ❑ <br /> CHECKN I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> G <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 /> FO/,9,J�A(3-2-BB) <br /> C <br /> L71 <br /> DATA PROCESSING COPY y+ <br />