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r <br /> STATE OF CALIFORNI WATER RESOURCES CONTROARD <br /> FORM <br /> UNDERGROUND STORAGE TANK PROGRAM � o <br /> SITE I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION b <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C FORN P <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PEITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE wo— I <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) MT <br /> FACILITY/ T NA," , f,•w /� CARE 0 ADDRESS INFORMATION <br /> (� lvhlC t .crt�2 �tZ <br /> !•V <br /> ADDRESS v' NEAREST CROSS STREET ✓Bozloibicale ❑ NEASHIP ❑ STATE-AGENCY <br /> &�J ❑ CORPORATION LOCAL-AGENCY ❑ FEDERAL-AGENCf h <br /> VII-44 ❑ INDNIDUAL COUNTY-AGENCY <br /> CITY NAME n STATE ZIP CODE SITE ONE#,WITH AREA CQDE <br /> LU(��(jj/(-� CA 'L/a 0 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR 1:1 ,PROCESSOR ✓Box if INDIAN EPA ID q #of TANK's <br /> ❑ RESETION <br /> 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAM (LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NA. E(LAST,FIRST) PHON #WITH AREA CODE <br /> ,0 3JY-S� Y , <br /> NIGHTS: NAME(LAST,FIRST) PHON #WITH AREA CODE NIGHT : AME(LAST,FIRST) PH E#WITH AREA CODE <br /> 5/A .4 ]I/A <br /> II. PROPE TY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CAR RESS INFORMATION <br /> MAILIN STREET ADDRESS ✓Box to indicate OXRTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION V LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NA VA <br /> STATE � ZIP CO E PHONE ,WITH ARE ,^ <br /> S <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NA , / A CARE OF RESS INFORMATION <br /> L 444 <br /> MAILING or TRE A(DRESS --•/v ✓Box to indicate ElB4PTNERSHIP ElSTATE-AGENCY <br /> ,,••-- � <br /> ElCORPORATION LOCAL-AGENCY ElFEDERAL-AGENCY <br /> I I to-- 1:1INDIVIDUAL E] COUNTY-AGENCY <br /> CITYAME . STgIEA ZIP jt?y PHON�#, LTH PMDE, <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS Q^ /`` <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111. <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> d D 3 3 z D D 1:�� <br /> CURRENT LOCAL AGEN"C�Y FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> J <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FI D <br /> �� YES ❑ NO ❑ � <br /> CHECK M PE MIT U T 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 /> F RMA(3-2-88) <br /> DATA PROCESSING COPY / <br />