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STATE OF CALIFORNI)V' WATER RESOURCES CONTROTBOARD FORM IA': UNDERGROUND STORAGE TANK PROGRAM SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANE Y CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT 1:14 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 —4 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILIN/SITEN ME ae CARE OF ADDRESS INFORMATION I VJ, ADDRESS NEAREST CROSS STREET ✓Bm In ❑ PAR NEBw ❑ trrATEAGENLY Q� ❑ PON ❑ LDCALAGDCY Cl RDEBAL-AGENCY 6 r D.DUI ❑ CWMY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N:WITH AREA CODE CA A D TYPE BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID ItRESE #OI TANKY E] I GAS STATION FARM ❑ 5 OTHER TRUSTYLANDS ATION or ❑ AT THIS SITE 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 NIGHTSNAME(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 ✓`.fir ✓Boz to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME , ^..• n CARE OF ADDRESS INFORMATION / MAILING or STREET ADDRESS w , ✓Bax to intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,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. Er II. ❑ 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# JURISDICTIONA, AGENCY# F #of TANKS at SITE CURRENT LOCAL AGENCY FACILI y/L,(// araC✓ ' ROVED BY PHONE N WITH AREA CODE PERMIT NUMBER I�c.lY PERMIT EXPIRATION DATE LCHECOC# CEN TRAC SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DATE FILED 3 OnC YES NO C/v 7 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N III / 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. — \YIn�I/ FORMA(9-2-88) Jr DATA PROCESSING COPY