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STATE OF CALIFORNIA... WATER RESOURCES CONTROI.eOARD s' FORMA`: UNDERGROUND STORAGE TANK PROGRAM = " ' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION c, COMPLETE THIS FORM FOR EACH ACILITY/SITE `"'ll..."" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYeLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILI ISITE NAME , _ CARE OF ADDRESS INFORMATION / o/yv7U ADDRESS NEAREST CROSS STREET ✓Bm0i4cele D P,WMFAHP D STATE AGENCY O� 57 F7 D COVOSTDN D LOCAL AGED D FEORVLAGDO 4 D IWONIWk D COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE 57�416v CA 95206 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID NRESEN of TANKY ❑ I GAS STATION ❑ 3 FARM El OTHER TRUST or ❑ 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 N 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 ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY Cl INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP Cl STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING 1NNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ N. ❑ 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY11, JURISDICTION R AGENCY N FACILITY ID If R of TANKS Y SITE ® " I I I " CURRENT LOCAL AGENCY FACILITY ID N APPROVED SY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE O �'3.w 3 YES NO FI `) CHECK N PERMIT MOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: C THIS FORM MUST BE ACCOWANIED 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)