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STATE OF CALIFORN19 WATER RESOURCES CONTROLBOARD 9e� , t v A FORM NA': UNDERGROUND STORAGE TANK PROGRAMr �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION FA rn ADDRESS (� / /' NEAREST CROSS STREET ✓aut N4NSV 0 PARTNERSHIP 0 STATE-AGENCY O � LOM G ❑ IEuENa ioUk ION O MUIPY GBa CITY NAME STATE ZIP CODE SITE PHONE IF WITH AREA ODE S CA S - - a TYPE OF BUSINESS: ❑ 2 DI TRIBIROR ❑4 PROCESSOR ✓Boz it INDIAN EPA ID p _ N of TANK's RESERVATION or AT THIS SITE ❑ 1 GAS STATION FARM ❑ 5 OTHEfl 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 IN WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION q MAILING or STREET ADDRESS ///��L ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY Q 1 7„(h - /) ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME N ✓Y �--� STATE DECODE PHONE IF WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/80.tointlicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION ❑ LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II.15K Ill.❑ 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 ��C,O�JUYY�NT # �� JURISDICTION N AGENCY N FACILITY IDD N M of TANKS M SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE CELL PERMIT NUMBER PERMIT APPROVAL DA TE PERMIT EXPIRATION DATE LOCATION CODE CENSUS Tf1ACT M SUPERVISOR-DnIBTRICT CODE BUSINE88 PLAN FILED DATE FILED �( d, YES ❑ NO 1.Z t vl CH CKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: ' THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. / FORMA(3-2-8e)