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rFACILITY/SITE E OF CALIFORNO WATER RESOURCES CONTRIPBOARD r. : UNDERGROUND STORAGE TANK PROGRAM = ' �a 2 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to COMPLETE THIS FORM FOR EACH FACILITY/SITE ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE F"a ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 00 TY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) .A A /SITE NAME CARE OF ADDRESS INFORMATION n i on r�c9S NEAREST CROSS STREET ✓Bm loir6#N 0 PARTNBBIIP 0 STATE AGEILY ^ +B-COPPDRTION 0 LOCAL-AGENC'! 0 FBIERAL 3i r , y-( 0 INDMWAL 0 CXIM-AGENCY ME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 00 cA BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's AS STATION ❑ 3 FARM OTHER TRUSRESETYLANDS ATION or ❑ AT THIS SITE U I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH ARFA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE �c Cl 39,921, NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY V, f;nt 2NDIVIDUAL 0 COUNTY-AGENCY CITY NAMEO STAT ZIP CODE PHONE#,WITH AREA CODE Ll q5a �0 2cf-1 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OFADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY 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. ❑ It. 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# JURISDICTION# AGENCY# FACILITY ID Is #of TANKS at SITE 6 1 O 1 1 Iq T�U I b0 lo CURRENT LOCAL AGENCY FACILITY ID# r '1 APPROVED BY NAME PHONE#WITH AREA CODE kCHECIE, V K MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CODE CENSUUS�TRRACCTT#�1 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED, 2J O V �"f ' —1 YES ❑ NO ❑ CCW 11,1.4-4 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: '"fir 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 ONUS FORM A(3-2-BB) `\J) DATA PROCESSING COPY