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STATE OF CALIFOR WATER RESOURCES CONT BOARD ^^ <br /> FORMA": UNDERGROUND STORAGE TANK PROGRAM "o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FA ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 1?15'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4=1, <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) �D <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓30,10 M.1, ❑ PARTNERSHIP ❑ STATE AGEND <br /> ❑ O <br /> OIVRATION 11 LOCAL AGENCY 1-1FEDERAL AGENCY <br /> S �- f-t , INIGUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODESITE PHONE p,WITH AREA CODE <br /> <E -S cGe /o.-7 CA Q'S3�D w _ - <br /> TYPE OF BUSINESS 2 DI TOR 4 PROCESSOR ✓Box if INDIAN EPA ID #FSATlON <br /> #of TANK's <br /> F-11 GASSTATION ❑Fil3 FARM E] 5 OTHER RgUSI LANDS or ❑ AT THIS SITE Q <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS'. NAME(LAST,FIRST) PHONE It WITH <br /> 'AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> zek <br /> NIGHTS: NAME(LAST,FIRST( PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRSTI PHONE#WITH AREA CODE <br /> 41 3 G r✓- <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Q S <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III, TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SL[♦'saf c[ S <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,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. ❑ 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION At AGENCY# 7NAME <br /> #of TANKS at SITE <br /> 3 <br /> CURRENT AGENCY FACILITY ID# APPROPHONE#WITH AREA CODE <br /> PERMIT NUMBER RMITAPPROVAL DATE ATION DATELOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODEN FILED DATE FILED <br /> 3 9 0Z 3 a(o NO ❑CHECK# PERMIT AMOUNT SURCHARGE AMOUNT RECEIPT# BY:: <br /> V� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MNK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) O A <br /> 2 � �� DATA PROCESSING COPY <br />