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STATE OF CALIFORNO WATER RESOURCES CONTROBOARD / "'F"` ��r FORMA': UNDERGROUND STORAGE TANK PROGRAM #e A�e SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION v COMPLETE THIS FORM FOR EACH FACILITY/SITE 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 �Q IC I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FAGu SITE NAME '. 1 CARE OF ADDRESS INFORMATION L' L 1?Nlft IN VICE ✓41 N ADDRESS NEAR ST CROSS STREET min&ral# Cl PARTNERSHIP ❑ STATE AGESp r N RPDHATION ❑ LOC.ALAGENC` ❑ EAGENLY C �/ ! L_ /� ��+ ❑ INOMOUAL ❑ COIINIY AGENC! MLA/ CITY NAME / STATE ZIP CODE ITE PHONE#,WITH AREA COD ` ,4'17 ON cA -2nZ 207 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Boz if INDIAN EPA ID # - It of TANK'# RESEATION ❑ 1 GAS STATION ❑ 3 FARM THER TRUST LANDS or ❑ AT 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 ex/144 _f M . v — / NIGHTS. NA (LAST, PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME �y I CARE OF ADDRESS INFORMATION f _ If MAILING or STREET ADDRESS Y.46 to intlicate ❑ PARfNERSHIP ❑ STATE-AGENCY ORPORATION ClLOCAL-AGENCY ❑ ERAL-AGENCY ❑ INDIVIDUAL 11COUNTY-AGENCY rt4 CITY NAME STATE ZIP CODE P E# I HAREA CODE Z III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMF/I CARE OF ADDRESS INFORMATION C C� MAILING or STREET ADDRESS io indicate ❑ PARTNERSHIP ❑ STyTE-AGENCY /5-r57-r. ORPORATION ❑ LOCAL-AGENCY GSIDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY l/ {C CITY NA STATE ZIPCODE I 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: L ❑ IL 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACIL TY # If of TANKS at SITE Eil I 1 1 161 �)In 10 CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE 107 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONCODE CENSUSTRACT# SUPERVISOR•DISTRI TCODE BUSINESS PLAN FILED DATE ILED R.YES F] NOEJ I �G1 / J CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: rA302ST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. DATA PROCESSING COPY