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.... ...,.w,I•;/�:�r.4``J;..:Y-a.rv9��'vC'."CRF}R" irv�"."int+R-�R'�.T"A'n01'9y�a!F9/]�} �-e"/ STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMA': UNDERGROUND STORAGE TANK PROGRAM V �' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION i COMPLETE THIS FORM FOR EACH FACILITY/SITE `'Arron" f c MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE A ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I.Ifl I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE ME CARE OF ADDRESS INFORMATION ADDRESS _ NEAREST CROSS STREET ✓Bmlo iplp ❑ PATMUSHV ❑ STATEAGDO 0 CUPGMi1GN 0 L➢GAL-AGOO 0 FEDWL-AGENCY (J 0 INp k 0 DWNWAGENLY CITY NAME STATEZIP CODE SITE PHONE N.WITH AREA CODE n CA TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box H INDIAN EPA 10 N ❑ t GASSTATION ❑ 3 FARM ❑ S OTHER RESERTRUSTYATION LANDS or ❑ N of AT THISHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N 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 ✓Boz w'I,d'c.o Cl PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL Cl 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 ✓Box to mdc.t. 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 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: I. ❑ II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY K FACILITY ID If M of TANKS at SITE =1 / I I I I 10 CURRENT LOCAL AGENCY FACILITY ID 4 APPROVED BY NAME PHONE N WITH AREA CODE F / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRI SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3_22YES ❑ NO ❑ /,D %� O� CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAS "I OR MORE TANK PERMIT FORM `B'APPLICATION(S), I'" 7SS THIS IS G SIT�FORMATION LY. �C FORM A(3-2-SS)vj AV\ �—� \ In ✓\ I DATA PROCESSING COPY I