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G STATE OF CALIFORNI8 WATER RESOURCES CONTRIOIOARD FORM IA,: UNDERGROUND STORAGE TANK PROGRAM SITE '-<x .FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � z COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Cc I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W C.TI FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 1 ADDRESS NEAREST CROSS STREET ✓Bm IoA m Cl PA ESHIP C STATEAGRILT C CNPORATION C LOCAL AGENCY C FEDERAL AGERCI J C IRCmDuA1 ❑ COUM AGENCY CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ a PROCESSOR ✓Box d INDIAN EPA ID # #of TANK'# ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE 1 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(PAST,FIRST) PHONE#WITH AREA CODE Il. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Intlicale C PARTNERSHIP ❑ STATE-AGENCY C CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY ❑ INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓80x to indicate C PARTNERSHIP C STATE-AGENCY ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY ❑ INDIVIDUAL C 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. ❑ 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(PAINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY M FACILITY 1D a M of TANKS a1 SITE m I a 0= I I I 10 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE '\ [OECATION CODE CENSUS TRAC(`TM0 SUPERVISSOR-OISTRICT CODE BUSINESS PLAN FILED DATE FI 0 o h # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE VES Na ED ❑ 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. I\ FORM A(3-2-68) I�/ -�7z� 1 DATA PROCESSING COPY