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STATE OF CALIFORNIA- WATER RESOURCES CONTROL BOARD FORMA': UNDERGROUND STORAGE TANK PROGRAMa SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑ fi TEMPORARY SITE CLOSURE J 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) CD J FACILITY/SITE NAME CARE OF ADDRESS INFORMATION PAtiel a NN Maes ADDRESS NEAREST CRO STREET - m ❑ PARTNE-RSWP F1 STATE-Amcf i✓ AWONMEl LOGAGEY ❑ M)FRA00 ❑ IWkNWAL ❑ WUNT(AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE S(oc CA TYPE OF BUSINESS: ❑2 DISTRBUTOR ❑4 PROCESSOR ✓Boz A INDIAN EPA ID # ❑ I GAS STATION ❑ 3 FARM El OTHER TRUST LANDS or ❑ AT TH S SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Boxto,ncicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAIUNG or STREET ADDRESS ✓Box to imicele ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 11,WITHAREACODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ACOP!ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ if. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY_,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It AGENCY# FACILITY ID It #of TANKS at SITE I 15= CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE If WITH AREA CODE &"Et50 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 2 3.'GQ z S YES ❑ No p 90 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: C f. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B' APPLICATION($), UNI ESS THIS IS A CHANGE OF SITE INF'O'RMATION ONLY. x�FORM A(3-2-BB) ATA PROCESSING COPY y