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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD A FORMA". UNDERGROUND STORAGE TANK PROGRAM <o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / 4/ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EIK CHANGE OF INFORMATION ❑ 7 P TLY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) QD FACILITY/SITE NAME ( CARE OF ADDRESS INFORMATION L�JEIZ7R Al 0 ADDRESS NEARESTTCRO§S STREET ✓6ornntinV 0 PARTNERSW 0 STATE-AGE10 YZiDN ❑ fD AAGF PVL 11 mwtx ❑ =ArY AUNLY CITY NAME STATE ZIP q S DW v SITE PHONE 0,7✓1 /AREA CODE TYPE OF BUSINESS: ❑p DISTRBUTOR / ESSOfl Box if INDIAN EPA ID N �l Bol TANVK'F ❑1 GAS STATION ❑3 FARM 5 OTHER TRUSTVLANDS ATION m ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE B WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to indicate El PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY 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 ❑ IL ❑ 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 B JURISDICTION B AGENCY B FACILITY ID B B of TANKS EI SITE CURRENT LOCAL AGENCY FACILITY! B APPROVED BY NAME PHONE B WITH AREA CODE /L6/-"2 � PERMIT NUMBER PER MIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT[B SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO ❑ ��y p,Il J CHECKI PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT BY; p 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. RMA(3-2-BB) �A R� I ) / DATA PROCESSING COPY `�