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STATE OF CALIFORNIx WATER RESOURCES CONTROL BOARD FORMW: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o o COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ T NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F-% ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C6 00 a) li I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) CII FACILI ITE NAME CARE OF ADDRESS INFORMATION CA ADDRESS NEAREST CROSS STREET ✓BNIrniak 0 PAMERSHIP 0 TATE AGENCY (�— yj ❑ WIPONATION 0 LOCA4AGFN(X ❑ FEIXIUL-AGENCY ❑ INOMWAI ❑ Q]UNiYAGMLY CITY NAME 1 STATE ZIP CODE SITE PHONE N.WITH AREA CODE IV\ CA TYPE OF BUSINESS: ❑p DISTRIBUTOR 4 PROCESSOR ✓Box iI INDIAN EPA ID # ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTLANDSATION o ❑ 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(I-AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP Cl STATE-AGENCY 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to milcate 0 PARTNERSHIP Cl STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ III.❑ 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 If AGENCY# FACILITY ID R N of TANKS at SITE m I o CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE It WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODECENSU!TRACT• SUPERVISOR-DI8TgICT CODE BUSINESS PLAN FILED DATE F LED �3. FSO 3a YES [-] NO ❑ g CHECK# PERMIT AMOUNT SURCHARGE MOUNT FEE CODE RECEIPT# 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 IN 7ON ONLY. ��)ORM A(3-2-88) A. DATA PROCESSING COPY low