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STATE OF CALIFORNIA WATER RESOURCESCONTRO*OARD FORM IA': " UNDERGROUND STORAGE TANK PROGRAM =" o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `" COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 ILLY CLOSED SITE ONE ITEM ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bm to Wi 11 PARTNERSHIP Cl STATE 37, 92/ 6 \ 11 CORPORATION 0 LOCAL ENCYElFEDERAL-AGENC Y 11 N11 FAGNIY CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE v CA fj5- 6 �q--P2_H RE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Bax if INDIAN EPA ID 4 ❑ It of TANK's I GASSTATION [:] 3 FARM ❑ 5 OTHER TRUSTYLANDS VATION dr ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA COOS 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 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE Ill. 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 4,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. ❑ 11. ❑ 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 COUNTYTI JURISDICTION# AGENCY M FACILITY ID N N of TANKS el SITE aI I I i / 14 1 1 1 1 1 �Z_ CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE io-� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO�(N CODE CENSUS TRACT N SUPERVISOR-D I xSTR ICT CODE BUSINESS PLAN FILED DATE FI D (l 2/ 2i l/b YES NO 0 /z CHECK# PERMITAMOUNT 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 ON FORMA(3-2-SS)