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OF <br /> STATE OF CALIFORNP WATER RESOURCES CONTROL BOARD <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION . <br /> COMPL TE THIS FORM FOR EACH FACILITY/SITE Cq�FORN P <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 E <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) C" <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAR ST CROSS STREET ✓Box to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> ❑ CORPORATION ElLOCAL-AGENCY 1-1FEDERAL-AGENCY <br /> 1-4 In; tic.- ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE V ZIP CODE SITE PHONE#,WITH AREA CODE <br /> S CA 0 Ca01 D <br /> TYPE OF BUSINESS: # <br /> 2 DISTRIBUTOR F-14 PROCESSOR ✓Box if INDIAN EPA ID <br /> ❑ ❑ TRUST RESERLANDS ATION or ❑ #of HIS SITE <br /> 1 GAS STATION 3 FARM 5 OTHER 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#WITH AREA CODE <br /> q a~ala <br /> NIGHTS: NAME(LAST,FIRST) PHO E#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> _q I1214� <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME SS CARE OF ADDRESS INFORMATION <br /> �.1 GL� <br /> MAILIN or STFkfT ADDWS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#,WITH AREA CODE <br /> � S]h G c o <br /> Ill. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> OaA- <br /> MAILING or STR ADDRESS ✓Box to indicate ElPARTNERSHIP ❑ 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 <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 /> PPERMITNUMBER <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> gl � 1 oQ d <br /> IMC 93 <br /> NCY FACILITY ID# APPRO ED HONE#WITH AREA CODE <br /> PERMIT P ROVAL AT PERMIT EXPIRATIO AJA <br /> CENS STRACT# SUP R ISOR-DISTRICT CODE BUSINESS LAN FI DDATE FILED <br /> 3� YES NOalu <br /> PERMIT AMOUNT SURCIIA GE 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 /> FORM A(3-2-88) <br /> • DATA PROCESSING COPY • <br />