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T..w... '"„'s' a" "nll !93iy' `.'et `.�4■ <br /> STATE OF CALI FO R N I.-. WATER RESOURCES CONTRL_ BOARD ' O•, 'HF <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM ��` � ado <br /> SITE ",FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> .10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE CgtiF RSP <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 /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) (TI <br /> f-� <br /> FACILITY w CARE OF ADDRESS INFORMATION <br /> /SITE A E <br /> ADDRESSNEAREST CROSS STREET ✓Boz 10 indicate PARTNERSHIP ❑ STATE-AGENCY <br /> ^' / ❑ CORPORATION LJ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME / STATEZIP CODE SITE PHONE#.WITH AREA CODE <br /> S�O �U�✓ CA <br /> TYPE�IGAS <br /> BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # <br /> ❑ ❑ TRUSTVLANDS�r ❑ #of TANK'S <br /> STATION 3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME T.FIRST) oPHONE WITH AREA CODE DAYS: NAME(LAST,F PHONE#WITH AREA CODE <br /> zk <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AAREA CODE NIGHTS: NAME(LAS/FIRST) PHONE#WITH AREA CODE <br /> v/ i <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME n CARE OF ADDRESS INFORMATION <br /> J\ G�y�e �S <br /> MAILING or STREET ADDRESS ✓Box to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> EI CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME � ' CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 44ARTNERSHIP Cl STATE-AGENCY <br /> ❑ CORPORATION LJ 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 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 /> EI o z 0 o0a <br /> CURRENT LOCAL�ttICCIL� # APPROVED BY NAME PHONE#WITH AREA CODE <br /> ZA <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CID CENSUS TR T k. SUPERVISOR-DIST T COPE BUSINESS PLAN FILED ❑ DATE FILE <br /> 2 YES NO i <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY, ��- <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 /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />