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STATE OF CALIFORA WATER RESOURCES CONTRO BOARD %r'*'', y0.P� o N\ UNDERGROUND STORAGE TANK PROGRAM = ' o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��oa�" MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE N ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ro*jo I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) .8h. CO FACILITY/SITE NAME I �/ CARE OF ADDS I'N;ORMATIO� AODF S ^(rte' AREST CROSS STREET ) ✓E0lOWIooa ❑ PARTNERSHIP ❑ STATE AGENCY 1 �- /^� f.1_ -Y,^C ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDEMLAGENGY µ Q ❑ INONDUAL ❑ COUNTYAGENCY CITY NA STATE ZIP CODE SITE PHONE R.WITH AREA CODE Cs071 CA qs3Lc) TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID ft ❑ 1 GASSTATION ❑ 3 FARM ER TRUSTRESEVLANDS ATION Gr ❑ AT THIS SITE 0 ' EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS Ni FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE otf-� Russel q 19 -- NIGHTS: NAME(IAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION rn MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME M CARE OF ADDRESS INFORMATION 11� MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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. 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 COUN FYY# JURISDICTION N AGENCY N FACILITY ID N N of TANKS at lo SITE ` /� CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 1 YES NO (�` ( .C.' � CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: ii 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. FORMA(3-2-88) J 0 DATA PROCESSING COPY 0