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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD A W A UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE �# ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) ♦W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W l Fj ADDRESS NEAREST CROSS STREET ✓OmbNok D PARTNERSHIP D STATE-AGENCY D CAIPOMTION D LOON-AGENCY D FEDPW AGENCY ❑ INGMDUAl D COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE Lc. j t CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID N RESERVATION or #of TANK'# J ❑ 1 GAS STATION ❑ 3 FARM ❑ S OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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 ✓Be.to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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 ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY R FACILITY ID R If of TANKS BI SITE Eq I I I T= I I I I In CURRENT LOCAL AGENCY FA ILITY IDk APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROV DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# - PERVISOR-DISTRI T CODE BUSINESS PLAN FILED DATE FILED 3 R4� YES NO 0 2 CHECK# PERMIT AMOUNT SUR ARGEA NT FEE CODE RECEIPT BY: 1 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. FORM A(3-2-88) •.WJ h NOW DATA PROCESSING COPY �