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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMA`: UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 42 .4 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY S TE NAME CARE OF//ADDRESS INFORMATION N ADDRESS NEAREST CROSS STREET ✓ Nltlok 0 PARTNERSHIP 0 STATE AGENCY lz CGPOMTION 0 LOCAL AGENCY 0 FEDERAL AGENCY 0 INDMWAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE 4.WITH AREA CODE CA U -y6 -4623 TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ PROCESSOR ✓Box if INDIAN EPA 10 S of TANK' RESERVATION or S4 ❑ I GASSTATION ❑ 3 FARM W5 OTHER TRUSTIANDS ❑ 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 4 WITH AREA CODE O NIGHTSNAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) N ' CARE Of ADDRESS INFORMATION AME MAILING or STREET ADD SS ✓iBox to indicate 0 PARTNERSHIP Cl STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY O 0 INDIVIDUAL 0 COUNTY-AGENCY ITV NAM STATE ZIP CODDE�E^^ PHONE N.WITH AREA CODE 01 1 91�l�� III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY Cl 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: 1. ❑ II. 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION S AGENCY S FACILITY ID S S of TANKS SI SITE [HE] FH CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE S WITH AREA CODE � PEp A NUMBER� PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACTS SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 2 YES NO 7 �U CHECK S PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT V BYE 4/77 l 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, ORM A(3-2-88) L/