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STATE OF CALIFORNI11 WATER RESOURCES CONTRAOARD FORM `I UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH CILITY/SITE Qq� FO NSP MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N CC-CA SLC 41v� ADDRESS NEAREST CROSS STREET ✓Ow IO indrcate ❑ PARTNERSHIP ❑ STATE-AGENCY C� ❑ ICOORP17�RAtTION El CDUNTYGENCY ❑ FEDERAL-AGENCY CITY NAME STATE 21P CODE SITE PHONE H,WITH AREA CODE d" d CA S2 . TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID H ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TR!STVLANDS or ❑ M o}TANKSITE AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE At WITH AREA CODE DAYS, NAME(LAST,FIRST) PHONE H WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE H WITH AREA CODE NRGHTSNAME{LAST,FIRST) PHONE H WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate d PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY M FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE H,WITH AREA CODE 111. TANK OWNER INFORMATI N & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY _ ❑ INDIVIDUAL 11COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE H,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 PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORR€CT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 1I JURISDICTION N AGENCY w FACILITY ID N #I of TANKS s1 SITE CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE M WITH AREA CODE °7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED YES NO CHEC M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N By THIS FORA)MUST BE ACCOMPANIED BY AT LEAST(1 OR MORE TANK PERMIT FO R M 'S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88)