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STATE OF CALIFORN10 WATER RESOURCES CONTROBOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATI ° I <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT El4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -4 <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CO00 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST Q(iOSS STREET ✓ xtPi Ri TIO ❑ PARTNLOCAL AEN ❑ STATE FEDERAL <br /> EDERA AGENCY <br /> OO A (1� �� / 'jkl ez 4 <br /> CORPORATION ❑ COUNTY <br /> ❑ FEDEAALAGENp <br /> W 11 INDIVIDUAL ❑ ClJUN1V AGENCY <br /> CIN NAME <br /> S— STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> C v G <br /> CA 6 WI Z 1536 <br /> TYPE OF BUSINESS 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID 4 _ #of TANK'N <br /> ❑ 1 GASSTATION ❑ 3FARM ❑ 50THER TRUST LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PAYSte (LAST,FIRST) PHONE k-1 AREA CODE DAYS. NAIFIRSI) WITH A3REAsCODE <br /> AND <br /> A SL✓9 2 �SOZ") f _Slg Z09— S/— <br /> NIGHTS: NAME( .FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME( .FIRST) PHONE 4 WITH AREA CODE <br /> � /r <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMESCARE OF ADDRESS INFORMATION <br /> pTt�l65 c o1. <br /> MAILING or STREET ADDRES4 <br /> 8D0 /� -/Box to intlicate [I PARTNERSHIP ❑ STATE-AGENCY <br /> 'l(p <br /> El CORPORATION 11 LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ^(R. UfO ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE <br /> C <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME A CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toin4icate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 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 If It of TANKS at SITE <br /> 3q �� D 0 00 oZ <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE <br /> AND g <br /> r;;7 <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> S TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> OE <br /> YES NO17KN AMOUNT 0 V SURCHAR E AMOUNT FEE CODE RECEIPT p BY.��N <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) l <br /> DATA PROCESSING COPY <br />