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STATE OF CALIFO u y�"` °`~ <br /> WATER RESOURCES CO L BOARD ���"E" <br /> UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° , a ifs <br /> rcCOMPLETE THIS FORM FOR EACH FACILITY/SITE cgUFORN P <br /> MARK ONLY 1-11 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRES7 NEAREST CROSS STREE ✓Bo mdicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �)�p RPORATION ClLOCAL-AGENCY ClFEDERAL-AGENCY <br /> L' (/ ` ,/�I r ❑ INDMDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE SI E PHONE#,WITH AREA CODE <br /> �S' CA a a <br /> TYPE OF BUSINESS: F__j 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK'. <br /> El GAS STATION [:]3 FARM ❑ 5 OTHER TRUST LANDS ElAT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> D0 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME y CARE OF ADDRESS INFORMATION <br /> 14 <br /> MAIL-N or STREET ADDRESSaofo indicate ❑ PARTNERSHIP ElSTATE-AGENCY <br /> y� (( R CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NXME7 STATE ZIP CODEPHONE#,WITH AREA CODE <br /> C 3 <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME n CARE OF ADDRESS INFORMATION <br /> J c r � <br /> MAIJr STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> Z O ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME _ STATE w ZIP CODE PHONE#,WITH AREA CODE <br /> C r1J L <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: 1. ❑ 11. ❑ 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 US ONLY <br /> PPERMITNUM <br /> J ISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [M I I I I L I 100-M m o00 IDA <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> ` O4` <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDDATE F LYES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 8 <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 /> FORM A(3-2-88) ^ <br /> DATA PROCESSING COPY � ,_`/\- <br />