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STATE OF CALIFORNIV WATER RESOURCES CONTRO BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM SITE I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CLOSED SITE I `� O FACILITY/SITE NAME CARE OF ADDRESS INFORMATION c) t,) �AI NAME ❑ CORPORATION D LOCAL -AGENCY D FEDERAL -AGENCY ADDRESS NEAREST CROSS STREET ✓prm rdicale ❑ PARTNERSHIP ❑ STATE'AGEND u ZIP CODE PHONE #, WITH AREA CODE 1l fARPoUAl- ❑ ❑ FEDEML'AGEN CY lh. COLLAGEN Cl INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE 4, WITH AREA CODE �2(Pol� CA 6� ti -4 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P SSOR ✓ Box if INDIAN o EPA ID a �E STATE N of TANK's 21 ❑ 1 GAS STATION [—]3 FARM OTHER TRUST\ATION LANDS ❑ / (.{_ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS. NAME (LAST. FIRST) PHONE N WITH AREA CODE c -R -b y- 0 FEE CODE RECEIPT N BY: NIGHTS'. NAME (LAST. FIRST) PH E A WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) III TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ✓Box to,Rtlicate ❑ PARTNERSHIP Cl STATE AGENCY NAME ❑ CORPORATION D LOCAL -AGENCY D FEDERAL -AGENCY CARE OF ADDRESS INFORMATION ❑ INDIVIDUAL D COUNTY -AGENCY Po M I u ZIP CODE PHONE #, WITH AREA CODE CURRENT LOCAL AGENCY FACILITY IDN ✓8 Rtlicale ❑ PARTNERSHIP ❑ STATEAGENCY MAILINGor STREET ADDRESS ORPORATION 11LOCAL-AGENCYClFEDERAL -AGENCY T �/ 6� ❑ INDIVIDUAL ❑COUNTY -AGENCY PERMIT EXPIRATION DATE STATE ZIP CODE HONE p, WITH AREA CODE CITY NAME 1 DATE FILED pr III TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ✓Box to,Rtlicate ❑ PARTNERSHIP Cl STATE AGENCY MAILING or STREET ADDRESS ❑ CORPORATION D LOCAL -AGENCY D FEDERAL -AGENCY FACILITY N ❑ INDIVIDUAL D COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING' I. ❑ if. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED 8 SIGNATURE, DATE LV VAL f1 COUNTY K JURISDICTION N AGENCY k FACILITY N k of TANKS at SITE (IIDD I T 8 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE pa►.�3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED NO DATE FILED pr YES CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM 'BI APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORMA (3-2-8SI DATA PROCESSING COPY