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STATE OF CALIFORNIN' WATER RESOURCES CONTRABOARD J.. FORMA': °`�-�:. .' �m UNDERGROUND STORAGE TANK PROGRAM =` g SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 14 COMPLETE THIS FORM FOR EACH F CILITY/SITE ��e=`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT IK5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CIL SED SITE f-► ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 -4 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) N A FACT TY/SIT_E NAME CARE OF ADDRESS INFORMATION �N ADDRESS _ 5 Joe let) NEAREST CROSS STREET ✓B.W'%mIA 11 PARTNERSHIP El STATE AGENCY y �❑ RPORATION ❑ LOCAL AGENCY ❑ FEDERAL IIYfNDIVIDUAL ❑ COUNTY AGENCY CITY NAM STATE ZCODE SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID 0 RESERVATION or #of TANK's ❑ 1 GASSTATION �3 FARM ❑ 5 OTHER TRUST LANDS 171AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OFADDRESS INFORMATION MAILING or STREET ADD ESS -/Box t.,nd,c.to ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ 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 MAILING.,STREET ADDRESS ✓Box to mole ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE 1.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. ❑ if. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY lY JURISDICTION If AGENCY M FACILITY ID k N of TANKS at SITE 'q 101l II CURRENT LOCAL AG NCY FACILITY IDN APPROVED BY NAME PHONE IN WITH AREA CODE L /7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCCODE CENTS-1U8 TRA+CTIM2 SUPERVISOR-DIS A OTRICT CODE BUSINESS PLAN FILED GAT FILED Q'G 4•�xO-�7 YES NO E] CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 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 ONLY. FORM A(3-2-88) DATA PROCESSING COPY