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T STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM IA': °^`.� Z UNDERGROUND STORAGE TANK PROGRAM Via `+ SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �0 Z COMPLETE THIS FORM FOR EACH FACILITY/SITE ___O cq ir1 10 oa `^ MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT ONE ITEM �5 CGE OF INFORMATION � 7 PERMANENTLY CLOSED SITE 1..► 2 INTERIM PERMIT q AMENDED PERMIT 6 TEMPHANORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CTI FACILITY/SITE NAME r CARE OF ADDRESS INFORMATION ADDRESS cpqw flo'll '��uess �1 �• NEAREMCROSS STREET p✓�.Bo.NNW El p�mIp 0 STATE AGENCY CITY NAME ,v ' Du V4k\ l ^`-' CINPGIUiM ❑ IOGLAGENLY ❑ FEDSSL4GENGY ❑ Iwwn..AI ❑ WIINTY.AGENCY L STATE ZIP CODE SITE PHONE��,p,vpWITH ARE9A COpE♦ TYPE OF BUSINESS: � p DISTRIBUTOR �A pROCE3SOR ✓Box it INDIAN EPA D CA %290— � � —3 _~09+ I GAS STATION 3 FARM 5 OTHER RESERVATION or - #of TANK' N TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) SS ^2 JUPHONE p WITH AREA CODE NI��++TSPSME(LAST,FI ) N PHONE#WITARREA CODE NIGHTS NA�ME,(LAST,FIRST) PHONE N WITH AREA CODE E�s II. PROPERTY OWAER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION E � MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY Cl 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 ✓Boz to,nd,cale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ 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 IENICN ABOVE ADDRESS SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I-M I. E:l If. 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 Al AGENCY# FACILITY ID# #of TANKS at SITE y ] I bda I ODO CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE a WITH AREA CODE L.aDI N I Z PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE rCICE ATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 2::. YES NO C / CK N //PPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# SY: 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(3-2-00) �_a DATA PROCESSING COPY