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iF CALIFORNIA• WATER RESOURCES CONTROLOARD i"n" uhf i UNDERGROUND STORAGE TANK PROGRAM = " o FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION i COMPLETE THIS FORM FOR EACH F CILITY/SITE "•�^—"-" ARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 1115 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION u7e tea ADDRESS NEAREST CROSS STREET ✓autr ¢ 11 PARTNERSHIP ❑ STATEAGENCY p 13 CORPORATION 11LOCALAGEND ❑ FEDERAL AGENCY L G� ❑ INGNIOUAL ❑ CGUNTYAGEND CITY NAMESTATE ZIP CODE SITE PHONE#,WITH AREA CODE C_ v CA () TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PR9PESSOR ✓Box if INDIAN EPA ID 0 RESERVATION ora of TANK's •'� E] I GASSTATION E] 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE <= EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY NAME(LAST,FIRST) f PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE D;y� Inh 1 953 8" NIGHTS'. NAME(LAKT, CFIRST) ^�^�,�, PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE J a//A Kn/J' II. PROPERTY OWNER INFORMATION &AD RESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST)kE COMPLETED) NAME RE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ BPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY ❑ IN (DUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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. ❑ it. ❑ 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 S AGENCY B FACILITY ID R R of TANKS at SITE CURRENT L CAL AO NCY FACILITY ID N APPROVED BY NAME PHONE S WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CME CENSUS T ACT SUPERVISOR-018TRICT CODE BUSINESS PLAN FILED DATE FILED a YES NOE] CHECK♦ PERMIT AMOUNT SURCHA GE AMOUNT FEE CODE RECEIPT BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION FORM A(3-2-88) 0 ' •