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STATE OF CALIFORNM WATER RESOURCES CONTR*BOARD UNDERGROUND STORAGE TANK PROGRAM SITE, FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m. , ELICOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION7 NT Y CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 7_' I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) fACI /SI_TZ N ME CARE OF ADDRESS INFORMATION (/tet N ADDRESS NEAREST CROSS STREET ✓Bu b itlrele D PARTNERSHIP D STATE AGENCY .'l �� ❑ WWOR ION ❑ LOX AGENCY ❑ FEDEMLAGENCY "iC ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA L TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P ESWR I ✓Box it INDIAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM 5 OTHEfl RESERVATION or ❑ J`ld*-zc.e_ AT THIS SITE TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE At,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. ❑ 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 K JURISDICTION M AGENCY K FACILITY IDM R of TANKS N SITE SOC/. CURRENT CµAGENCY FACILITY ID N APPROVED BYHA E PHONE N WITH AREA CODE 17 1 PERMIT NUMB/ERC PERMIT APPROVAL DATE RMIT EXPIRATION DATE E CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED q�q 3T YES NO > rtiPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM •B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) �" FORMB(6-29-88) mis rvmwwrve,o.^^--••--- DATA PROCESSING COPY