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a STATE OF CALIFORNle WATER RESOURCES CONTROL BOARD / ` ''"• FORM 'I UNDERGROUND STORAGE TANK PROGRAM V �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; COMPLETE THIS FORM FOR EACH F ILITY/SITE `^�„pe„,> 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT E!r5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY TE IV ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 01 0 I.FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) V FACILITY/SITE NAME CARE OF ADDRESS INFORMATION I ADDRESS NEAREST CROSS STREET ✓Bm mintlicile 0 PARTNERSHIP 0 STATE AGENCY C ❑ MKRATION 0 LOCALAGENCY 0 FEDERAL AGENCY ❑ INDIVIDUAL 0 WUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box A INDIAN EPA ID # RESERVATION❑ NK 1 GAS STATION ❑ 3 FARM OTHER TRUSTT LANDS or ❑ AT THof IS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) P146E#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & AD ESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.to indicate 0 PARTNERSHIP D STATE-AGENCY D CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MOST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME TATE I ZIP CODE PHONE It,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOT LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND N THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY11, JURISDICTION# AGENCY# FACILITY IDM #of TANKS at SITE Liu 1010111613161 CURRENT LOCAL AGENCY FACIL TY ^I APPROVED BY NAME PHONE M WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCN COIN CENSU "ACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED — �{ 3 l/I YES NO CHECK# PERMITAMOUNT 1901FICHARGE AMOUNT FEE CODE RECEIPT IT BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST Ill OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNI FSS THIS IS A CHANGE OF SITE INFORMATION ONLY. STORM A(32-88) V� W DATA PROCESSING COPY