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STATE OF CALIFORNIA • WATER RESOURCES CONTROL &RD FORM IA': UNDERGROUND STORAGE TANK PROGRAM 0 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC FACILITY/SITE c" FOR MARK ONLY ❑ I 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) FACILITYISITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓CORtO TIO 0 PARLOCAL A ENC 0 STATFERE AGENCY _ ❑ COAPOMiION ❑ LOCAL AGENCY Cl FEOElU4AGENCY IV,1 5G� ❑ INDYWAL ❑ COUNTY AGENCY CITY NAME V1 STATE ZIP CODE SITE PHONE N,WITH AREA CODE /•vl CA S�D� TYPE OF BUSINESS: DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i11ND1AN EPA ID p - #of TAN K'# RESERVATION or AT THIS SITE ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHEfl TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) N CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS _ -/ ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY Pyn S I [3 CORPORATION ClLOCAL-AGENCY 1:1 FEDERAL-AGENCY S \ - A 0 INDIVIDUAL 0 COUNTY-AGENCY C�NAME STATE ZIP CODE r7 PHONE AREA CODE � l/' ,7`5 7/l III. TANK 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#,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. ❑ 110 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 R JURISDICTION M AGENCY# FACILITY ID R k of TANKS at SITE ffijig ACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE SUSTRACTN SUPERVISOR-0111 ICT CODE BUSINESS PLAN FILED DA FILD YES ❑ NO ❑ /MIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 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 0 LY. FORM A(3-2-88) 4441 IsA '6,�"_