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STATE OF CALIFORNIPi WATER RESOURCES CONTROCBOARD FORMA`: UNDERGROUND STORAGE TANK PROGRAM sl FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m r, COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ / NEW PERMIT ❑ 3 RENEWAL PERMIT 215 CHANGE OF INFORMATION ❑ 7 PERMANE LOSEO SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 21 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME / ®� CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ambioc& ❑ PARTNERSHIP ❑ STATE- AGENCY �, GK O COW M,TION ❑ LOCLA NCY ❑ RMEWAGENCY O IN)mOuu O cwmn NcY CITY NAMEIlN✓1 ^ STATE ZIP CODE SITE PHONE p,WITH AREA CaPE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box A INDIAN EPA ID p J ❑ I GAS STATION [—] 3 FARM 5OTHER I ESE TRUSTYIANDS or ❑ NBITANSI IAT 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 NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME , CARE OF ADDRESS INFORMATION MAILING o,STREET DDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL O 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 o STREWADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE 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 BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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* JURISDICTION S AGENCY N FACT 1 N of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE I CENISUS TRACT'3N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED T7 I 'A 3 . 1A 01- a.7 YES ❑ NO ❑ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM •S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88)