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STATE OF CALIFORNIA WATER RESOURCES CONTROLOARD P`EP` \s, FORMA': UNDERGROUND STORAGE TANK PROGRAM =" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , COMPLETE THIS FORM FOR EACH FACILITY/SITE FMARKONLY ❑ T NEW PERMIT F] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE z 80 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION /VS S A 11r,lrc4 ADDRESS ��// NEAREST CROSS STR/ET ✓Bov to lntlicale ❑ PAATNEASHIP ❑ STATEAGENCY /// E, �� (� /L ❑ CDIVIDUALDN ❑ CO NTYAGENCy A.AGENCY [I FEDERAL AGENCY W CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE 00 CA TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCES ✓Box it INDIAN EPA ID # V q of TANK's RESERVATION or ❑ I GASSTATION ❑ 3 FARM HER TRUST LANDS ❑ � ,e AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST, IRST) NE#WITH AREA CODE NIGHTS. NAME(LAST, ST) PHONE WITH AREA CODE z 39 -y z,r II. PROPERTY O NER INFOR ATIO &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to md,cate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax tointlicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY'AGENCY CITY NAME STATE ZIP CODE PHONE ft,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. EiK If. ❑ If. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY v II COOUTIINTY# II JURISDICTION# AGENCY# FACILITY ID S #of TANKS at SITE TYO Eil GENICCILITYIDD# APPROVED BY NAME / PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE S TRACT# SUPERVI R-DISTRICT CO E BUSINESS PLAN FILED DATE FILED ha7 YES NO LZIT 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 ONLY. FORMA(3-2-88) • DATA PROCESSING COPY 0 tv