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STATE OF CALIFORNIA WATER RESOURCES CONTROL BL OARD FORMA': UNDERGROUND STORAGE TANK PROGRAM = " .e " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o �{ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I,qI NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY DSITE ONE ITEM 2INTERIM PERMIT 4AMENDED PERMIT 6 TEMPORARY SITE CLOSURE a) I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) iR F Cl ITY/SITE NAME CARE OF ADDRESS INFORMATION / A A D 1ES19 NEAREST CROSS STREET �✓ A161merIe ❑ PARTNERHP ❑ STATE AGENCY N Ig cGnrolwnaN El LOCAL AGENCY ❑ rEDEFAL AGENCY u womouAL ❑ COUNTY AGENCY CI ME AirSTATE ZJE C,ODF SITE PHONE N,WITH AREA CODE a CA Ly o Oil TYPE OF BUSINESS: 2DISTRIBUTOR ❑4PROCESSOR ✓Box if INDIAN EPA IDN Nof TANKs 1 GAS STATION 3 FARM �S OTHER RESERVATION LANDS or '�" a � 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 N WITH AREA CODE LO - 3 NIGHTS: NAME(LASTPHONE N WITH AR A CODE NIGHTS: NAME(LAST,FIRST) �,��I PHONE N WITH AREA CODE .FIRST) 1 ✓ l 7 II. PRO ERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION I MAILING or STREET AD RESS Id CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY DoEl PARTNERSHIP El STATE-AGENCY I ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE s7o O Z09- 41(p 7- 06 3 Ill. O - III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION .SA MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N,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: L ©' II. El 111-07 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. PPLICANT'SNAME RI ED&SIGNATURE) DATE a LOCAL A NCY USE ONLY COUNTY N JURISDICTION N AGENCY R FACILITY ID N B of TANKS at SITE 9 / 0�3 o � CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE N PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PECK TI /CODE CENSUS TRACTN SUP SOW(STRICT CODE BUSINESS PU NFILED ❑ DATE FILED �•/•� R3 3 YES NO J PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(SI, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.. FORM A(3-2-lid) 0 DATA PROCESSING COPY 'Not i