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,_..�. .. _......--..m...��.: __.xn,...,..,..�enm•.,�-,nA'ARA^�4.IV1NL4jnp,., ..._o...�.�wv:rm ., .. . .. STATE OF CALIFORNIA* WATER RESOURCES CONTROL BOARD FORMW: UNDERGROUND STORAGE TANK PROGRAM ' mol SITE Z FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION \ / COMPLETE THIS FORM FOR EACH FACILITY/SITEa- MARKONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGEOFINFORMATION ❑ 7 PERMANENTLY CLOSED SITE P-z ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE CSI 41 J1 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME I CARE OF ADDRESS INFORMATION ADDRESS /J NEAREST CROSS STREET ✓Box to ind.le D PARTNERSHIP D STATEAGENCY N��tn UA�laN OUNYncEN7 1EGEBAtaGENcr0 I�oviDO CTCr C 14 NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE C&-co' o CA TYPE OF BUSINESS'. ❑ pISTRIBUTOR ❑ 4 PROCESSOR I/Box If INDIAN EPA ID 4 ❑ I GAS STATION 3 FARM ❑ 5 OTHER TRUSTYIANDS 0 ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box ❑ tD PARTNERSHIP D STATE-AGENCY CORPORATION D LOCAL-AGENCY ❑ FEDERAL AGENCY V ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to indicate D PARTNERSHIP D STATEAGENCY ❑ CORPORATION D LOCAL-AGENCY Cl FEDERALAGENCY D INDIVIDUAL Cl COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,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. 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE H;7-3-m CU!IEN AL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 5� PEU RMIT APPROVAL DATE PERMIT EXPIRATION DATE N CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 2 , - �'� '3 2 s VES NO 6 (] CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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) \v�,J ' ^ C �j b DATA PROCESSING COPY V�J l