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STATE, OF CALIFOI WATER REsouRCEsc yEP.�° rhf <br /> ONTROL oARD <br /> FORMA.- <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Y �' <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE Cq�,p�RN,P cCl <br /> MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ TLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 47 all <br /> I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> FACILITY/SITE NAME I <br /> r CARE OF ADDRESS INFORMATION <br /> �NTP, sY e J <br /> ADDRESS /6 NEAREST CROSS STREET ✓Ba i ed cele ❑ PMTWMIP ❑ STATE-AGENCY l ❑ coBPGNa ION ❑ LCL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDNIDIIAL ❑ MINTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA f <br /> TYPE Of BUSINESS: ❑2 DISTRIBUTOR ®4 PRO( SSOR ✓Box if INDIAN EPA ID# 2 <br /> ❑1 GAS STATION ❑3 FARM ❑5 OTHER TRUSTRESEVATION LANDS or If of❑ AT HIS SITE J <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NN3HTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY 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 It.WITH AREA CODE <br /> III. TANK OW,.,ER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREETADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NO-TIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1jrBOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 111.❑ <br /> THIS FORM,,MS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APP.LICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCALAG9 <br /> NCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #Of TANKS at SITE <br /> l EE <br /> o <br /> CURRENT LOCAL,AQENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT It SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> D Z 6 ® 3 2, YES ❑ NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMIPANIED 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 /> 1 <br />