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5fn'`i orti.Th'• . STATE OF CALIFORINA WATER RESOURCES CON*L BOARD r. FORMA": UNDERGROUND STORAGE TANK PROGRAM =`° o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 ' 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �/ � I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) A FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS y^ S NEAREST CROSS STREET ✓S,,to irdiwle ❑ PARTNERSHIP ❑ STATE AGENCY /V / ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ❑ INDrvIDUAL ❑ COUNTY AGENCY CITY NAME V STATE ZIP CODE SITE PHONE#,WITH AREA CODE �C 1- CA TYPE OF BUSINESS: ❑ 2 DIST TOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'e �^� ❑ I GAS STATION ARM ❑ 5 OTHER TRUSTYLANTitDS ATION dr ❑ � _ AT THIS SITE Cy_ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE /`.^ ZYo7 NIGHTS'. NAME(LAT,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 or STREET ADDRESS ✓Be.to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION Is AGENCY# FACILITY ID If #of TANKS at SITE o CURRENT LOCAL AGIII EACILITYI II APPROVED BY NAME PHONE It WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXPIRATION DATE LEIPERMIT SUS TRACT 2 SUPERVISOR-DISTRICT CODE BUSINESS PSN FILED NO ❑ DATE Iii? AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 6 Z13Y4 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(3-2-881 DATA PROCESSING COPY