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STATE OF CALIFORNI01 WATER RESOURCES CONTROL OARD p <br /> FORMW: 0 Z <br /> UNDERGROUND STORAGE TANK PROGRAM 0 <br /> ® <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION10 <br /> ! <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY <br /> 1 NEW PERMIT F-13 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ❑ N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CTT <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> /� Scu <br /> ENCY <br /> ADDRESS <br /> ENFARESTROSS STREET 1 CORPORATION ❑ Lle El ARTNERSHIP STATE OCALA E CY ❑ FEDERAGAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ZIP CODE SITE PHONE#,WITH AREA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Bax if INDIAN EPA ID # #of TANK's <br /> 5 OTHER RESERVATION or ❑ AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate 1:3 PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNIY-AGENCY <br /> STATE ZIP CODE PHONE If.WITH AREA CODE <br /> CIN NAME <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 /> COUNTY# JURISDICTION It AGENCY# FACILITY ID If #of TANKS at SITE <br /> G G U U U <br /> CURRENT LOCAL AGENCY FACILITY�10 N <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> NV <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE SUSINESIt;PLAN NFILED NO <br /> ❑ DATE FILE <br /> ocvc <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 /> \V�_J\ DATA PROCESSING COPY <br />