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5 SEP�[��.xFe STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD V UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMA ENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 41ro a I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FAGILITY/SITE NAME /_ CARE OF ADDRESS INFORMATION 7fe-ANS m�7Ps-!I� W NEAREST CROSS STREET 'B I'd IG ❑ PARTNERSHIP ❑ STATEAGENCV IV ADDRESS 1 0 �, `;N JE-lit ( ❑ INDIVORPIDUAL COUNTY❑ COUNTY AGENCY LOCAL AGENCY 0 FEDEAAbAGENCi T CITY NAME s Q / STATE ZIP 00�� / SIT P ONE p,WITH AREA CODE 1f �,/I TYPE OF BUSINESS 2 DISTRIBUTOR J�4 PROCESSOR ✓Box if INDIAN EPA ID # At of TANK's ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSRES TVLANDS ATIONo ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST). PHONE k WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST FIR ) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME -4 ,( CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box to indicate 11 PARTNERSHIP ❑ STATE-AGENCY �� V07 ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITU NAME STATE'_ ZIP CODE / PHONE kiITH AREA CODE gs EAN NCIS60 G S/yy/ III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING ar STREET ADDR ✓Box to in ESS El PARTNERSHIP El STATE AGENCY nhj �� (AIM1 1007 E] CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY GIN NAME ^ STATE ZIP�(/�OOE,/0 PHONE p.WiTH AREA G.0'DE 41 AN IV. LEGAL NOTIFICATION AND BILLING ADDRESS S CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION k AGENCY# FACILITY ID F It of TANKS at SITE CURRENT LOCAL AGENCYFACILITY ID If APPROVED BY NAME PHONE M WITH AREA CODE `s0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE rCHECK# ION DE CENSUS TRACTA O SUPERVII - ISTRICT CODE BUSINESS IPLAN FILED NO ❑ DATE FILED PERMITZAM UNT SURCHARGE AMOUNT FEE CODE RECEIPT Of 8 BY: IS 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. F A(3-2-88) DATA PROCESSING COPY )