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STATE OF CALIFORNIA WATER RESOURCES CONTROBOARD FORMW: m UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , COMPLETE THIS FORM FOR EAC2 FACILITY/SITE FMARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE PV ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S J I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) pvD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION (e ra 1` MfkSE row 1I r ADDRESS /� NEAREST CROSS STREET ✓UP,tPMIUY 0 PARTNERSHIP ❑ STATEAGENCY El CORPORATIEl LOCAL AGENCY r SCA T� N /J+ P / 1• 0 INDIIVIDUALGN 11COUNTY AGENCY ❑ FEDERAL AGENGY CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE S , < o,J CA ?,6 _�3 TYPE OF BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # RESERVATION or #of TANK'# ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS 1:1 AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(IAST,FIRST) PHONE#WITH AREA CODE k r 1/6 3 NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE H.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(i)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ 111. ❑ 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 �� CCO�UNT/Y7�'# JURISDICTION# AGENCY# FACILITY ID# // #of TANKS at SITE 1=17-1 = /=T/ P CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE � - ro PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3�— YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THISFORM MUST BE ACCOMPANIED BY AT LEASTI)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), LESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1 �` FORMA(3-2-88) wj / � �l 1 ^ y, il,(J�C 11VIY1 DATA PROCESSING COPY (�U ` "