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;STATE OF CALIFORN WATER RESOURCES COABOARD FORM W: ate= ' % UNDERGROUND STORAGE TANK PROGRAM SPMARK FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONCOMPLETE THIS FORM FOR EACH F ILITY/SITEONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �+ I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 20 FACILITY/SITE NAME � , CARE OF ADDRESS INFORMATION i a1 vvn 2r�w ADDRESS NEAREST CROSS STREET ✓Box aVNca@ 0 PARTNERSHIP Cl SIAIEAGENCY N a ❑ COA'OM"M 0 LOG4AGENLT ❑ FEOE0.4L. ENLY co ❑ INDVIGUAI 0 CWNMAGENCY CITY NAME ^w STATE ZIP CODE SITE PHONE N.WITH AREA CODE '_4 TYPE OF BUSINESS: ❑2 D TRIBUTOR F+❑4 PROCESSOR ✓Box it INDIAN EPA IO p ❑ I GASSTATIDN FARM ❑5 OTHER RESERVATION or 1:1 #of TANK's AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 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 INFORMAI ION MAILING or STREET ADDRESS ✓Box to inchwe ❑ PARTNERSHIP D STATE-AGENCY D CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box tom ,case D PARTNERSHIP Cl STATE AGENCY ❑ CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY ❑ 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. ❑ if. ❑ 111.❑ 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 N #of TANKS of SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE_ / C0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISCODECODE BUSINESS PLAN FILED DATE FILED a a a e� YES ❑ NO / a CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: / 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. 'L r� \ ^ y� DATA PROCESSING COPY 6AOJ1