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STATE OF CALIFORNIA' WATER RESOURCES CONTROL` WARD ^j FORMA': UNDERGROUND STORAGE TANK PROGRAM' . s SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONm �- COMPLETE THIS FORM FOR EACH FA ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PER964NTLY 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 O,' ADDRESS NEAREST CROSai�2 +dixim ❑ PAITNERSNP ❑ STATE AGDO 6 6 !� G/e G /r , iWIVIDUALIGN o �A EN o FE AGS CITY NAME ^ I STATE SITE PHONE p�WITH ARE: DE CA TYPE OF BUSINESS'. ❑ P DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N !q/V^ N of TANK s ❑ I GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS ION 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 ❑ PARTNERSHIP D STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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 ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl 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 WHICH ABOVE ADDRMBB SHOULD BE USED FOR BON LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111•❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY N FACILITY ID R R of TANKS M SITE 3 � a3 U CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE 00(iSl;� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION DE CENSUS TRACT^ 8-0• SUPERVISOR-DISTR CODE BUSINESS PL32, AN NG N FILED ❑ DATEFILED - CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY. 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. 6 ORM A(3-2-58)