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STATE OF CALIFORNO WATER RESOURCES CONTROL BOARD 5f`........ FORMW: UNDERGROUND STORAGE TANK PROGRAM All, SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , I t� A COMPLETE THIS FORM FOR EAC ACILITY/SITE CgC,FO R!P MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE V I. FACILITY/SITE INFORMATION 8t ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME ,/ CARE OF ADDRESS INFC TMATION A ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY j3506 RPORATION E3LOCAL-AGENCY ElFEDERAL-AGENCYVI I�x/� INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE aCA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR -/Box Box if INDIAN EPA ID # RESE❑ 1 GAS STATION rZ/FARM ❑ 5 OTHER TRUST LANDS ATION or ❑ TAT f T IS SITE THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE '94,fd NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE it WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl 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 zl"01 Rlnsrz MAILING or STREET ADDRESS ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY Z_Z_ �G��v�"� ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY lll(�V"✓� ❑ 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. ❑ II. ❑ III. tr 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 ENB JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE ENCY FAACITY ID APPROVED BY NAME PHONE#WITH AREA CODE ?PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ATE FILED 23. �� S' YESPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY; p 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. U FORM A(3-2-88) DATA PROCESSING COPY