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STATE OF CALIFORNR WATER RESOURCES CONTROL'BOARD FORMA`: UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PER IT APPLICATIONm COMPLETE THIS FORM FOR EACH F ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA ED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ft WWxab 0 PARTNEMP 0 STATE AGENCY /GJr,-V/C// ❑ fAN El LOCAL ❑ EW AGENCY V 0 INDMDUAL MWAL ElCWNtt AGENCY CITY NAME STATE ZIP CODE SITE PHONE X,WITH AREA CODE Sc to CA C2 -J'3k -3j0P_ TYPE OF BUSINESS: ❑ p DI Ofl ❑ 4 PROCES60fl ✓Box if INDIAN EPA ID k X 01 TANK1 RESERVATION Or ❑ AT THIS SITE ❑ 1 GASSTATION 3 FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE X WITH AREA CODE 2 o NIGHTS: NAME(LAST,FI T) PHONE X WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE k WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS 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 X,WITH AREA CODE III. TAW( OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING ar STREET ADDRESS ✓Bax to iod,.ate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M,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: 1. 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 COUNTY X JURISDICTION X AGENCY X FACILITY ID M K of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE X WITH AREA CODE a -"7- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L\V LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Q 73a� �/ YES NO �) CHECK V PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X BY: GjC112, Sl9 0 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 d�1LY. \ FORM A(3-2-88) 1