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, ATE OF CALIFC)RI WATERy ..QF Ty` FORM RESOURCES CONT L BOARD p.. E �t�� -.e `A'. UNDERGROUND ST fql� ORAGE TANK PROGRAM IWC xo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Y COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ERM TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 1:1 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) :O FACIL�L� CARE OF ADD E S INFORMATION I� ,P. 1. . Low' All' A ADDRESS radNEAREST CR S STREET ✓ to inkale ❑ PARTNERSHIP ❑ STATF-AGENCY PO v W✓YN.�� ©RV O)UALON ❑ COUNTY AGENCY ECI LOCAL AGENCY ❑ FEDERAL-AGENCY CITY NAPE co ,1�, STATE ZIP CODE SITE PHONE k,WITH AREA CODE CA) CA 4F 1 pct TYPE OF BUSINESS: E 2 DISTRIBUTOR 4 PROCESSOR '/Box If INDIAN EPA ID r 1 GAS STATION Ej 3 FARM E] 5 OTHER RESERVATION or #of TANK's TRUSTLANDS El AJ IA AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DRAYS. NAME(LAST,F ) .JPHONE 4 WITH AREA CODE DAYS'. NA E(LAST,FIRST) PHON It WITH AREA CODE NIGHTSNAME(LAST.FI�rST) PHONE H WITH AREA CODE NIGHTS: [ N[f.ME(LAST,FIRST) PHO4 WITH AREA CODE ('i+hc -� p jA S IL. PROPERTY OWN9R INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME _T— CARE YJADDRESS INFORMATION II JA MAILING or STREET ADDRESS yam. ✓ '01N Ia indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ��JJJ fNDIVIDUAL ❑ COUNTY-AGENCY CITY NAME L STAy��'TIF w ZdP CO`.D+E�] f/r.,yJPHONE#,WI H AREA CODE moo{/`-' A4 J d� ( L Ili. TANK OWNER IN ORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF DDRFSS INFORMATION MAiLI or STREET HESS ox to indacate ❑ PARTNERSHIP ❑ STATE-AGENCY y� �� • CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PH N R,WITH AREA CODE - CA IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING; I. IL III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANO TO THE BEST OF MY KNO WLFD6E, IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE G PERMIT NUMBER PERMIT APPROVAL DATE PER EXPIRATION DATE LOCATION CODE CENSUS TRAjC�T/+# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED OG . .�`3 �[1 Lr YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# a THIS FOAM MUST RE 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) DATA PROCESSING COPY