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TATE F ALIF RNID <br />S O C O WATER RESOURCES CONTROL�ARD �: •••E�AFKj'•hE <br />FORM `A': y� <br />UNDERGROUND STORAGE TANK PROGRAM zo <br />SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br />toll- COMPLETE THIS FORM FOR EACH F CILITY/SITE Cq(/FORN�P <br />MARK ONL F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />ONE ITE ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE .3 <br />1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) I <br />F ILITY/SITE NAW <br />�J <br />0 / 2 <br />FACILITY ID # <br />Q101Q <br />CARE OF ADDRESS INFORMATION <br />RENT LOCAL AGENCY FACILITY ll # <br />ADDRESS <br />RMIT NUMBER <br />EAREST CROSS STREET <br />Al 8 scale ❑ PARTNERSHIP ❑ STATE -AGENCY <br />—� <br />G <br />TION CODE <br />v <br />clams <br />ORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY <br />BUSINESS PLAN FILED <br />YES ❑ NO ❑ <br />FILE <br />/ aj/or/ <br />NECK # <br />_ <br />❑INDIVIDUAL ❑ COUNTY -AGENCY <br />CITY NAME <br />RECEIPT # <br />TATCA <br />IP CO <br />ITE PHONE #, WITHARE DE <br />� <br />3 <br />/ E OF BUSINESS: ❑ 2 DISTRIBUTOR <br />❑ 4 PROCESSOR <br />✓ Box if INDIAN <br />EPA ID # <br /># TANK's <br />1 GAS STATION [:]3 FARM <br />❑ 5 OTHER <br />TRUSTT I ANI DS ON or ❑ <br />0 fV A <br />of <br />AT THIS SITE <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) <br />D/� NAME (AST, FIRST) <br />PHONE # WITH AREA CODE <br />DA NAME (AST, FIRST) <br />PHONE #�W(`ITH AREA CODE <br />N S V V,.�.. <br />// <br />...Z s <br />• �F IS <br />TIGHTS: NAME (AST, FIRST) <br />IIHONE <br /># WITH AREA CODE <br />HTS: NAME (AST, FIRST) <br />PHONE # WITH AREA CODE <br />11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />ADDRESS- <br />LEGAL <br />DDRESS- <br />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. ❑ 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 # <br />JURISDICTION # AGENCY # <br />FACILITY ID # <br />Q101Q <br />F of TANKS at SITE <br />RENT LOCAL AGENCY FACILITY ll # <br />OVED BY NAMXF � PHONE # WITH AREA CODE <br />RMIT NUMBER <br />PERMIT APPROVAL DATE <br />1 6A <br />PERMIT EXPIRATION DATE <br />TION CODE <br />v <br />NSUS TRACT # ERVISOR-DISTRICT <br />23-1107d <br />ODE <br />BUSINESS PLAN FILED <br />YES ❑ NO ❑ <br />FILE <br />/ aj/or/ <br />NECK # <br />PERMIT AMOUNT—SURCHARGE AMOUN I <br />FEE CODE <br />RECEIPT # <br />BY: <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM EB' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORMA (3-2-88) <br />DATA PROCESSING COPY <br />N <br />C" <br />Ga <br />4b <br />