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STATE OF CALIFORN11 WATER RESOURCES CONTROL FORMW: UNDERGROUND STORAGE TANK PROGRAM4 I ,° SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C 3 •m ° COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGL OF INFORMATION 7 PERMA ITE ONE ITEM 11 p INTERIM PERMIT G AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ) I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME A / CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS ST REST ✓Bola YWwV ❑ PARTNERSHIP ❑ STATE AGENCY D �UALN NC_ ❑ FEDERALAGENCY S I-ldd<v �� INCl CUDAcE N CITY NAME STATE ZIP CODE SIFE PHONE u,WITH AREA CODE CA S53�G TYPE OF BUSINESS. p OISTR UTOR F__] I PROCESSOfl ✓Box it INDIAN EPA ID p Y of TANK'F RESERVATION or ❑ I GAS STATION 3 FARM 5 OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAMERASEFIRST) PHONE A WITH AREA CODE DAYS. NAME(LAST I IHSi) PHONE 4 WIT H AREA CODE NIGHTSNAME(LAST,FIRST) PHONE 4 WIT H AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE X WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAM)`. CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Co.10 nid."Ie Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE x.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING o,STREET ADDRESS ✓Box Io m .cwe ❑ PARTNERSHIP ❑ STATE AGENCY E) CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIOOAI ❑ COUNTY-AGENCY CITYNAME STATE LIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(f)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. Ll III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINT ED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY Y JURISDICTION Y AGENCYAT FACILITY ID Y Y of TANKS a1 = = = 1 1 1111-175 CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE Y WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION COOE CENSUS TRACT Y SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Y I BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST MORE TANK PERMIT FORM 't4'APPLICATION(S), UNOTHIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-P-GET)