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STATE OF CALIFORI2 WATER RESOURCES CONTRO BOARD FORM A% ` UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 y COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-] 1 NEW PERMIT F-] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G- -4 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) O F-� FACILM/SITE NAME CAREOFADDRES INFORMATnnu R C�� iYlav�c� �jye�r — ber ADDRESS NEAREST CROSS STREET ✓ROKN MI 0 PARTNERSHIP 0 STATE AGENCY 5/^2 LI ��1 I OrU 7 A Ll 4 ❑ WRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY (P3 l_ 1 �.O�Q�' 61ei-TOVIDUAL 0 COUNY-AGENCY CITU NAME STATE ZI CODE SITE PHONE H.WITH AREA CODE ESCc,farl CA �S� C� ao� q (OS TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID At -__ X of TANKY � ❑ 1 GASSTATION ❑ 3 FARM THER TRUSTYLANDS o ❑ AT THIS SITE W EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE DAYS: NAME(LAST FIRST) PHONE R WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME I CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERALAGENCY 0 INDIVIDUAL Cl COUNTY AGENCY CITY NAME STgTE ZIP CODE PHONE k,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. 1wr II. ❑ If. ❑ 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 IN JURISDICTION N AGENCY k FACILITY ID k d II z 1 k of TANKS at SITE 3 q _ . _ 0R I IN 0 101 CURRENT LO A NCY FACILITY ID M APPROVED BY NAME PHONE X WITH AREA CODE PERMIT N MBER PERMIT APPRO117A.,l PERMIT EXPIRATION DATE LOCATION C E CENSUS TRACT _LSUPR SOR-DISTRICT CODE BUSINESS PUN FILED DATE F E^DI Z ' YES ❑ NO fal 3l vi cc CHECK PERMIT AMOUNT RGEAMOUNT FEE CODE RECEIPTM BY: THIS.FORM MUST BE ACCOMPANIED BY AT LEASWR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) • DATA PROCESSING COPY h