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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD J FORMA': UNDERGROUND STORAGE TANK PROGRAM SITE1 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 UP PERMANENTLY CLOSED SITE N ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Ql al I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) p FACILITY/$ITE NAME CARE OF ADDRESS INFORMATION L ADDRESS NEAREST CROSS STREET ✓Box loiMltd@ 0 PARTNERSHIP 0 STATEAGENCY i 0 CORPORATION 0 LOCAL AGENCY 0 FEDERAL if L ❑ INDIVIDUAL ❑ COUNT AGENCY CITY NA al STATEZIP CODE SITE PHONE#,WITH AREA CODE twi1 CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box If INDIAN EPA ID # RESERVATION or #of TANK'a �T 1 GAS STATION 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE Z EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,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 Cl PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 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. ❑ it. ❑ 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# #of TANKS at SITE CURRENT LO�CAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 1x PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F ED YES NO ' ) CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: T IS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FO A(3-2-BB) `� DATA PROCESSING COPY �.+