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STATE OF CALIFORNI:-c WATER RESOURCES CONTROL BOARD � F FORM W: UNDERGROUND STORAGE TANK PROGRAM " �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ! ' ': COMPLETE THIS FORM FOR EACH FA �ITY/SITE `^`�"- c0 j MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION TLY CLOSED SITE ny ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 0. 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION J O I+r( & OrUALCO ADDRESSO �� P- ./L NEAREST CROSS STREET ✓9mbidxxii 11PARENERVIP 11STATEAGEND S M A N ❑ 00WO AIION ❑ LOC1L AGDO ❑ FEMRAL AGEto ❑ INavwuu ❑ MMTYAGMCYEA CITY NAME STATE ZIP CODE BIT PHONE M,WITH All CODE CA 953'7 TYPE OF BUSINESS: 2 D OR ❑4 PROCESSOR ✓Box if I DIAN EPA ID 4 ❑ I GAS STATION 3 FARM ❑ 6 OTHER TRUSTESEVLANDS ATION m ❑ A7 HIS SITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME /}J/, A ,r) CARE OF ADDRESS INFORMATION 14 MAILING a STREET ADDRESS ✓Box to indicate 13 PARTNERSHIP 13 STATE-AGENCY 13 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 1:1 COUNTY-AGENCY CITY NAME _ STATE ZIP CODE PHONE p,WITH AflEA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 11COUNTY-AGENCYCITY NAME, STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. In It. ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION B AGENCY N CIL ITY IDM B of TANKS at SITE CURRENT LOCAL ADENAPPROVED BY NA PHONE M WITH AREA CODE PERMIT NUMBER PERMIT EXPIRATION DATE LOCATIFCOOE CENSUS TRACT S SUPERVISOR•DISTRICT CODE BUSINESS PLAN FILED DATE FILED YZ Z L t, YES NO 0 / ? — '7�CHECKPERMIT AMOUNT SURCHARGE AY NT FEE CODE RECEIPT BY: // �ti 1 HIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS HIS IS A CHANGE OF SITE INFORMATION ONLY. �- FORM A(3-2-BS) '�/` DATA PROCESSING COPY