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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'AF: UNDERGROUND STORAGE TANK PROGRAMo <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,mL to <br /> COMPLETE THIS FORM FOR EAC FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 CLOSED SITE I <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑0 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION III ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> F leUC14 _ <br /> ADDRESS �/L� F NEAREST CROSS STREET ❑ CgPo TMDN D LOM AGM El NDEPAL AGM <br /> L V � ^ IVA/ ❑ NDM K ❑ DDIAM fFI1CY <br /> CITY NAME i I�� STATE ZIP CODE/��/ SIT2_!n—.WITH AREA COODE <br /> TYPE OF BUSINESS: 2DISTRIBUTOR ❑ 1 ESSOR I/Box if INDIAN EPA IDN 66 <br /> RESERVATION or Rol TANK'F <br /> El I GAS STATION ❑3FARM SOTHEA TRUSTLANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> GAYS: NAME(LAST,FIRST) <br /> CO� PHONEp WITH AREA CODAVDNAME(LAST WITH <br /> SN V � Au ,1/67O7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE F WITH AREA CODE NIGHTS'. NAME(LAST.FIRSA PHONE F WITH AREA CODE <br /> `{ It <br /> 11. PROPERTY OWNER INFORMATION 6 ADDRESS- (MUST BE COMPLETED) <br /> NAME ����/ CARE OF ADDRESS INFORMATION <br /> GM/, Lim S 7N <br /> MAILING or STREET ADDRESS [I LOCAL-AGENCY <br /> / to lnEicele Cl PARTNERSHIP ❑ STATE-AGENCY <br /> El CORPORATII ( E 64 4C El INDIVIDUAL ON 11COUNTVAGENCY 11 FEDERAL-AGENCY <br /> CITY NAME �„ STAT - ZIP CODE / PHO <br /> E NE4,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COOFMMP_LETED) 6 <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to inolcele ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE 21P CODE PHONE F,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE 11)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. IrIII.❑ <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 A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY10 JURISDICTION R AGENCY R FACILITY ID R R of TANKS at SITE <br /> = = 10D 1 I � 6 010 101 <br /> CURRENT LOCAL AGENCY FACILITY ID R APPROVED BY NAME PHONE R WITH AREA CODE <br /> n� ��L .ems <br /> PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE <br /> LOCATON CODE CENSUS TRACT R SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D / Q O YES NO - <br /> CHECK R PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT R BY: <br /> THIS FORM MUST BE ACCOMPANIED Y AT LEAST(1)OR MORE TANK PERMIT FO RM 'B'APPLICATIONIS), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-50) <br /> DATA PROCESSING COPY y I <br />