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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONw c - COMPLETE THIS FORM FOR EACH FAC TY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EtKCIFANGE OF INFORMATION ❑ 7 PERMANENTL CL ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Im I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/ ITE NAVE �— �� CARE OF ADDRESS INFORMATION 1 1:1`7 !/AJ N ADDRESS 411NEAREST CROSS STREET ✓Rm toiMua ❑ PARTNERSHIP [DSTATE AGENCY�O —� ❑ CORPORATION ❑ LOCAL AGENp ❑ FEDERAL AGENCY Q ❑ INDIVIDUAL ❑ CODNTAGENCY A CITY NAME STATE ZIP CODE Sly PHONE Al WITH AREA CODE CA 5S3 -2c) TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR A SSOA I ✓Box if INDIAN EPA 10 It RESERVATION or #of TANK'# E] I GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) HONE#WDRAREA CODE DAYS: M (L T,FIRST) PHONE#WITH AREA CODE 'dx/S 9W y 6 - NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS'. NAME LA& FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADD ✓Bax to InOicate ❑ PA SHIP ❑ STATE AGENCY ❑ CORPORATION CAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE WITH AREA III. TANK OWNER INF ATION & ADDRESS — (MUST BE COMPLETED) ((� NAME / CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP E7 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ I. It. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACU.ITY ID# APPROVED BY NAME PHONE#WITH AREA CODE .P� 3b PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACT# - I SUPERVISOR-DIST ICTC OE BUSINESSPUN FILED NO ❑ DATE FILED CHECK# PERMIT AMOUNT / SURCHARGE AMOUN FEE CODE RECEIPT# BY: ass \ 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. FORMA(3-2-88) '" DATA PROCESSING COPY