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STATE OF CALIFORN1) WATER RESOURCES CONTRAOARD FORMW: i.rUNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, INFORMATION and/®r PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE �4C,Fa \P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION f ONE ITEM ❑ ❑ ❑ 7 PERMANENT Y CLOSED SITE 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILI /SITE NAME CARE OF ADDRESS INFORMATION l ct C2 cr�v ADDRESS12 0 ru 7 P \n /� NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP 11STATE AGENCY tJ J • W —�- ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY CITY NAME 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CSTATE ZIP CODE (/SITE PHONE a,WITH AREA CODE y.. TYPE OF BUSINESS CA �� \ /5 � I ❑ 2 ISTRIB OR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUST LANDS RESERVATION or ❑ #of TANK'e AT THIS SITE 13 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) D NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) re y)Yi �/� �� PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a 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 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL--AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE a,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME S a CARE OF ADDRESS INFORMATION 4s S � MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE a,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. II. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY P_ COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURREN LOCAL jqCY FACILITY ID k APPROVED BY NAME PHONE#WITH AREA CODE 1 PERM NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC&R0q&ODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED f� DATE FILED p� YES NO 5 / CHE # PERMIT AMOUNT SURCHARGE AMO NT FEE CODE RECEIPT# B . THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88)