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STATE OF CALIFORNIA WATER RESOURCES CONTROBOARD J. FORMA': UNDERGROUND STORAGE TANK PROGRAMo Ate" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z COMPLETE THIS FORM FOR EACH FACILITY/SITE 40 MARK ONLY ❑ 1 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE PV ONE ITEM ❑ p INTERIMPERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE r 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) t0 FACILITYISITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET 1//B.Minute ❑ PARTNERSHIP Cl STATE AGENCY 2 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA 95203 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a If of TANKs ❑ 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUSTYLANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH ARFA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION n MAILING or STREET ADDRESS 1/80.to indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 11LOCAL-AGENCY 11FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE - I q52-01 - Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Sox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. ❑ 11. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE [3El oo CURRENT LOCAL AGENCY FACILITY ID# PROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERjizikQ PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # BUSINESS PLAN FILED DATE FILED 01 Z3r20 YES NO ❑ I—IIICHECK# PERMIT AMOUNTFEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. J \ \ DATA PROCESSING COPY .y