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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM =o Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 4i to COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) w FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 1�01,� I ADORE CS / NEAREST CROSS STREET ✓8altm alt 0 PARTNERSHIP 0 STATE AGENCY ❑ CORPORATION ❑ COUNTY AGENCY ❑ iEGEf41AGENCY C-I a ❑ INDWIDUCORPORA1 ❑ LOUN AGENCY NLY CITYN STATE ZIP CODE SITE PHONE N,WITH AREA CODE -�C GL CA 9S 336 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IO p RESERVATION or ❑ N of TANK's ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS 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#WITH AREA CODE NIGHTS: NAME(I-RST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(IAST,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 Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY I 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. if. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A,SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION If AGENCY# FACILITY ID If If of TANKS at SITE ICURRENT ENCY FY F CILJ� APPROVED BY NAME PHONE N WITH AREA CODE I 'iS C��"b1 PERMIT NUMBER LPERMITPPROVAL DATE PERMIT EXPIRATION DATE CENSUS TRACTNSUPERVISOR-DISTRICT CODE BUSINES,P SN FILED NG ❑ D�/ICEDD l3 J CPERMIT AMOUNTSURCHARGE AMOUNT FEE CODE RECEIPTM BY: THIS FORM MUST BE ACCOMPANIED BY AT LUST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. (FORM A(3-2-68) DATA PROCESSING COPY