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or STATE OF CALIFORNIk' WATER RESOURCES CONTROL BOARD FORMI I A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T� D ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 5 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) FAGLRY/ NAMEr CARE OF ADDRESS INFORMATION " 2 FAS eY6i ADDRESS //�_ / , NEAREST CRO STR ✓MR..'Qi&a 0 NARBISNPLOCAL-Mlla 0 STATEMGBMN 0$INOMWAL� 0 C01111Ymcf 0 fE0FA1LlIiFNLY CITY NAM ` ' .� - STATE ZIP CODE SITE PHONE R.WITH AREA CODE c L CA T76 o?e 22 E36=SS3G TYIfE OF BUS [:]S NES2 DISTRIBUTOR E]4 R'gOESSOR SEpVAINDIAN TIC a EPA ID p A THIS SITE 3 I GAS STA ON F-13 FARM ❑5 OTHER TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: SIE( Fl ) PHONE M WI AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE Z NIGHTS NAME(LAB..FlRST) PHONE p WITH A EA CODE NIGHTS: NAME(LAST.FIRST) PHONE M WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ,tri as T MAILING or STREET ADDRESS ✓Box to indicale 0 PARTNERSHIP 0 STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY U INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION as MAILING or STREET ADDRESS ✓Box to indicate U PARTNERSHIP U STATE-AGENCY U CORPORATION 0 LOCAL-AGENCY U FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)B CATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ IIL❑ JHIS F S BEEN COMPLETED UNDER PENALTY OF PERJURY,ANQ TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANT' N E(PRI ED 8 SI A DATE WdAL AGENCY USE ONLY COUNTY* JURISDICTION B AGENCY11, FACILITY IDR S of TANKS at SITE " r ei o o 0 CURRENT LOCAL AGENCY FACI6gY ID R G�7 APPROVED BY NAME PHONE R WITH AREA 000E / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRAC�iTR SUPERVISOR-DISTRICT ODE BUSINESS!PLAN FILED EM 9 D 0 ? Z YES � NO E �CHECKR PERMIT AMOUNT SURCHARGE AMO FEE CODE RECEIPT• // 1A THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CNANGE OF SITE INFORMATION LY.