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STATE OF CALIFORNIAN-- WATER RESOURCES CONTROLevdARD �~ <br /> FORMA': <br /> o <br /> UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION a _ <br /> m. t <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE �""�""'� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P Y CLOSED SITE r <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ~ <br /> FACILITY/SITE NAMCARE OF ADDRESS INFORMATION <br /> TUTU _ SNils o <br /> ADDRESS NEAREST CROSS STREET ✓Aox ❑ PARTNERSHIP ElSTATE-AGDO <br /> A/ S L F/(/ VU/CiWVw INGMWALGN O❑ COUNTY AGENCY <br /> 11FEDERAL-AGENCY <br /> CITY NAME (�O STATE ZIP CODE SITE PHONE 11.WITH ARE CODE <br /> J CA S� — 6 6 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR n /PP&EMR -/Box if INDIAN EPA ID x <br /> wRESERVATION or KOI TANKY <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> M 0SQ Ueda M 6 467 5AA"z-- <br /> NIGHTS: NAME(LAS FIRST) PH NE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME f Mo1Z IQ( TLIAI CARE OF ADDRESS INFORMATION <br /> Atzeprrtlzggdq or- fegg#, 11 <br /> MAILING or STREET ADDRESSP//�� //'� �j `'n ✓ xto indicate 11PARTNERSHIP 11STATE-AGENCY <br /> TT��' lG V` ❑ ION ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> CA 952a <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S�e Ao <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl 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. lirit. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYIN JURISDICTION M AGENCY K FACILITY ID M K of TANKS at SITE <br /> = = = I do (Olq00o <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> K(%FIT L'� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCINECK# <br /> CODE CENSUS TRACT a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> QYES NO <br /> PERMIT AMOUNT SURCHARGE 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 /> FORMA(3-2-88) <br /> \./ DATA PROCESSING COPY <br />