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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD l. o� 4F yfP . T' FORMW: UNDERGROUND STORAGE TANK PROGRAM o SITE " FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Aa c� 1 (i �. COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq LIFOR&,I' E ARK ONLY 1 NEW PERMIT El 3 RENEWAL PERMIT Q S CHANGE OF INFORMATION ❑ 7 PERMA LOSED SITE I--i ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) CD FACISITE NAME CARE OFA DRESS INFORMATION ADD N A S SS ST E T ✓Baa IPORABte ❑ PARTNERSHIP ❑ ST AGENCY Cl7 T7 CORPORATION ❑ LOCAL-AGENCY OEA L-AGENCY ❑ INOIYIIAIAL ❑ COONIYAGENCY CITY N27 TE ZIP CODE SITE PH NE N.WITH AREA CqDE TYPE OF BUSIN€SS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN �} EPA ID # 1 GAS STATION ❑3 FARM Q 5 OTHER RESERVATION or Q ca N of TANK'a TRUST LANDSAT THIS SITE6_3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AR ODE DAYS: NAME ST,FIRST) PHONE# ITH AREA CODE NIGHTS: NAME( ,FIRST) PHONE#WITH AREA CODE NIGHTS: Npj(LAST.FIRST) PHONE M W TH AREA CODE SIA S rL3 JA A 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NA CARE 9FADDRESS INFORMATION r y&/ MAILIN�r�,p)r SjTRE ADDRE SI ✓Box to indicate ElPARTNERSHIP ❑ STATE-AGENCY l� (4 2j3 ❑ CORPORATION ❑ LOCAL-AGENCY F DERAL GENCY V ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NA STATE ZIP CQPE-�� PHONE p, ITH AREA CODE ICC' S ? 3 X1/2 III. TANK OWNER &FORMATION &ADDRESS— (MUST BE COMPLETED) NAME ICARE OF ADDRESS INFORMATION ,,,/ MAILING r STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE II,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: 1. ❑ If. i�, III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLkCAN T'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY F_ _ JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE [�M URRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE U.S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVIS -DISTRICT CODE BUSINESS PLAN FILED DAT L C YES E] NO� (,[/ CHECK# PERMIT AMOUNT SURCH R E OUNT 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 INFORMATION ONL 4 RMA(3-2-88) go DATA PROCESSING COPY