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ri SEP �a+s'TF< <br /> STATE OF CALIFORNIP WATER RESOURCES CONTROL OARD i <br /> ` <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM <br /> SIFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> T r; l� <br /> _ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ ) NEW PERMIT ❑ 3 RENEWAL PERMIT d? CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME _ CARE OF ADDRESS INFCRMATION <br /> It I'[1 S �- n C , N <br /> ADDRESS N ARESTCROSSSTREET FeElINDIVIDUk_ <br /> tor6ate ❑ PARTNERSHIP ❑ SATE-AGENCY (1° <br /> r„ %� + /� U p�� I f f [ �� P6AAT10N C❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> �l'� lh�v /7 C (! J ❑ CAUN>1'-nCsENCr <br /> CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> S f©�l� v—w cA c� (e <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a #of TANK's <br /> FARM 5 OTHER <br /> GAS STATION ❑ 2 ❑ <br /> TRUST LANDS or ❑ /V40 w AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS, NAME(LAST,FIRST} PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) HONE#WITH AREA CODE <br /> e Ca -5531 Ch aS Ch 417 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> 11, PROPERTY OWNER INF RMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BO%INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 91. ❑ 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# #of TANKS at SITE <br /> � 9 Fo- 1ar / 1 � 600 's <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER l PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION <br /> jCODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILE <br /> V ! ! (3 YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT LLCODE RECEIPT# Y: <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(3-2-88I <br /> DATA PROCESSING COPY <br />