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STATE OF CALIFORNIA- WATER RESOURCES CONTROX-60ARD FORMA': UNDERGROUND STORAGE TANK PROGRAM SITE T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; COMPLETE THIS FORM FOR EACH FACILITY/SITE FMARKONLY ❑ 1 NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F-17 PERMANENTLY CLOSED SITE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION eExx 1A r ADDRESS f NEAREST CROSS STREET ✓Bmlo YdNak ❑ FMTNERSIIP ❑ STATE-AGENCY S ✓/S lrJ �// ❑ CORPORATON ❑ LOCAL ACD0 ❑ FM4 AGENCY ❑ INDWIDUAL ❑ muNTY AGFNwr CITY NA STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA - S 36b TYPE OF B SINESS'. ❑2 DISTRIBUTOR ❑4 PROCESSOR I ✓Box if INDIAN EPA ID# RESE❑ i GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE It WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to md,cale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 ADORES$SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 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 R JURISDICTION R AGENCY# FACILITY ID R R of TANKS at SITE CURRENT LOCAL AGENCY FACILITY 10 P APPROVED BY NAME PHONE#WITH AREA CODE J (V n PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS -3 , TM�� BUPERVISOR-DISTRICT CODE BUSINESS PIAM❑FlLED NO O D FIj� YES CHECK# PERMIT•AMOUNT SURCHARGE AMOUNT FEECODE RECENT BY:� 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. FORM A(3-2-88)