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STATE OF CALIFORNIA WATER RESOURCES CONTRAARD FORMA': UNDERGROUND STORAGE TANK PROGRAM " , \(I SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l �= COMPLETE THIS FORM FOR EACH FACILITY/SITE 2^ ,_IC ^4 soar•�� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT , CHANGE OF INFORMATION ❑) PERMANENTLY C SED SITE I. ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 13 C I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) / v FACIUTV/ E NAMECARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓9o,tou Ie 0 PARTNERSHIP Cl STATE AGENCY 0 MKIATION C LOGLAGEND C FEDERALAGENLY C INDIVIDUAL Cl C0UNIYAGENLY CITY NAVIE G STATE ZIP CODE SITE PHONE N,WIT?H AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I/Box if INDIAN EPA D NA AN 's_ ❑ I GAS STATION ❑ 3 FARM 5 OTHER TESE RUSTVATION LANDS Or ❑ AT THIS SITE Q EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(IA$T,FIRST) PHONE N WITH AREA CODE kf at I^ r NIGHTS: NAME(LAST, IRST) PHONE AVITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATI N & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box tc Indicate C PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY C FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDR S — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY Cl CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY C INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOYE ADDRESS SHOULD BE USED OR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY *COUNTY N JURISDICTION R AGENCY B FACILITY ID N N of TANKS at SITE = CURRENT LOCAL AGENCY FACILITY ION APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA ION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED a YES NO -- CHECK, PERMIT AMOUNT SURCHARGEAMOUNT FEE CODE RECEIPT, BY: THIS FORM MUST BE ACCOMPANIED BY ATJfACT(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLr.�., F6RM A(3-2-88) 1` (�.r Y \Y\, 11/�1 '�\ • DATA PROCESSING COPY �!