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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMA': UNDERGROUND STORAGE TANK PROGRAMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH F CILITY/SITE oq"FO" MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S1TE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1© I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FA NAM NAME CARE OF ADDRESS INFORMATION C CARE OF ADDRESS INFORMATION MAILING/rOr STREET DDRESS 0 uT I ✓ xto 11 INDIVIDUALIDUAL indicate 11 PARTNERSHIP ❑ STATE -AGENCY CY ❑ FEDERAL -AGENCY ON ❑ COUNTY -AGENCY CITY NAME � ADDiD STATE CR Sf. NEAREST CRIOSSSTREEET ^REN� -;qwyVp to inbaile ❑ PARINOUIP ❑ STATEAGENCY LOCAL -AGENCY ❑ FEDERALY �4 BUSINESS PLAN FILED YES NO � a 11 NINVIDUAL❑OGUNIYCY CITY NAME FEE CODE STATE ZIP CODE B SITE PHONE N, WITH AREA CODE fo C CA 9 o TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ / P ESSOfl ✓ 13 ESE,if INDIATIONN RESERVATION Dr EPA ID N M OE TANKS ❑ 1 GASBTATION ❑ 3 FARM OTHER TRUST_ANDS ❑ Nom.[ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME LAST. FIRST) PHONE N WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE 8 z. ar ;t0�(o&-so NIGHTS: NAME (LAErr, FIRST) HONE # WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE Sayn II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION C CAR OF ADDRESS INFORMATION MAILING/rOr STREET DDRESS 0 Q. I OO 0 APPROVED SYNAME PHONE N WRAREA CODE ✓ xto 11 INDIVIDUALIDUAL indicate 11 PARTNERSHIP ❑ STATE -AGENCY CY ❑ FEDERAL -AGENCY ON ❑ COUNTY -AGENCY CITY NAME � CITY NAME STATE CR ZIP CODE PHONE N, WITH AREA CODE 95 CAo9 G -s l-oc CENSUS TRACCTT##) / fJ 1/ SUPERVVIISOOR•DIS ICT CODE 7 BUSINESS PLAN FILED YES NO � a III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION rn�hf FACILITY IID # # of TANKS at SITE O 10 1 / I ( I / LP 1610101/1 MAILING or STREET ADDRESS 01 ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY APPROVED SYNAME PHONE N WRAREA CODE ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ 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. ❑ II. 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 LOCAL AGENCY USE ONLY COUNTY N ay JURISDICTION S AGENCY B FACILITY IID # # of TANKS at SITE O 10 1 / I ( I / LP 1610101/1 CURRENT LOCAL AGENCY FACILITY ID /I 10 APPROVED SYNAME PHONE N WRAREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE Co CENSUS TRACCTT##) / fJ 1/ SUPERVVIISOOR•DIS ICT CODE 7 BUSINESS PLAN FILED YES NO � D FILED a300 CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # B 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. FORM A G-2-88) 4.' DATA PROCESSING COPY