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STATE OF CALIFORNIA- WATER RESOURCES CONTROtimdOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Q COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION l S v NEAREST CROSS STREET ✓Bab Miele 0 PARTNISNP 0 STATEAGDO ADORERS 0 CDWMTM 0 LOG4-AGFN.Y 0 FEDERALAGPN /O< jCL oO 0 INWDUu 0 mulmAGOICY CITY NAME STATE ZIP CODE , SITE PHONE N,WITH AREA CODE 15F� 7�tJ CA YSZD TYPE OF BUSINESS' ❑ 2 DISTRIBUTORn a PROCESSOR -/Box if INDIAN EPA ID N _ F of TANK# IL's-J" RESERVATION or F-1AT THIS SITE ❑ 3 FARM 5 1 GAS STATION ❑ OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(I-AST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE If WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION --&d 6'e-G (16, MAILING or STREET ADDRESS ✓Box 10 indicate ❑ PARTNERSHIP 0 STATE-AGENCY / y wG�jN �//� ❑ CORPORATION ❑ LOCAL-AGENCY [IFEDERAL-AGENCY '7 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE S4elE��llfTL' C-4 e7'5S2e III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sxrr,t R i ✓b F Ouia,Q r^ MAILING or,STREET ADDREBS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If.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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY R FACILITY ID R a of TANKS at SITE Ell CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATON CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATI.FILE YESNO [:] / CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: aaaaaaaaamill 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. F011M A(3-2-88) fV//