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STATE OF CALIFORNIAWATER RESOURCES CONTLAOARD <br /> FORMW: <br /> : UNDERGROUND STORAGE TANK PROGRAM ' <br /> SITE FACILITY/SITE, INFORMATION and or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EA H F LITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION E] 7 P CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME: CARE O ADDRESS INFORMATION <br /> ADDRESS NEARES F CROSS STREET ✓BmtoMule ❑ PARTNERSHIP ❑ STATEAGRNCY <br /> ❑ COAPORATION ❑ LOCAL-AGENCY ❑ FEDERAL.AG9C4 <br /> OAZ '06 El INOMOUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE SITE PHONE A,WI ?EA CODE <br /> ` C //JJJJ 3 #&j <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i!IN IAN EPA ID <br /> FATTHISSIM <br /> l TANK's <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSRESET LA DS ATION or ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PH NE#WITH A7A DO DAYS: AME(LAST,FIRST 7, PHONE N WITH AREA CODE <br /> NIGHTS: N E(LAST,FIRST) PHONE N WITH AREA CODE !NIGHTS NAME(LAST,FIRST} PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE CO D) <br /> J ►n_ //J�� CARE O ADDRESS INFORMATION <br /> N E <br /> AILING or STRE����[[[[ADORESS ✓ oz Io indicate ❑ PARTNERSHIP STATE-AGENCY <br /> yJC O ! O ❑ CORPORATION ❑ LOCAL-AGENCY ❑ DERAL-AGENCY <br /> �/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> Cl AME STATE ZIP CODE PHONE#,WITH REA CODE _ <br /> 111. TANK OW NFORMATI &ADDRESS - (MUST BECOMPLETED) <br /> NAME CARE C F ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS IP ❑ STATE-AGENCY <br /> ❑ CORPORATION LJ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <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. ❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANDTO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION rr AGENCYI# FACILITY ID* N o1 TANKS at SITE <br /> Ll I I 06 E�Eo0 1 ;4 <br /> CURRENT LOCALflCY FACILIjY iD N APPROVED Y NAME PRONE N WITH AREA CODE <br /> cr <br /> [yJ tel/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISO -0ISTRI ODE BUSINESS PLAN FILED DATE FILED <br /> � v YES ❑ NO ❑ r <br /> CHECK t PERMIT AMOUNT SURCHARGE AMOUNT FEE ODE 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 /> FORM A(3-2-88) • ' <br />