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Mrd STATE OF CALIFORNIA WATER RESOURCES CONTROLGARDr�ICJ FORMW: UNDERGROUND STORAGE TANK PROGRAM SITE ACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ;! " z COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Cyri CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) Lrl CJ"1 FACILITY/S7;NAME CARE OF ADDRESS INFORMATION I I ADDRESS - NEAREST CROSS STREET ✓Bmroratile Cl PMITNERSHP ❑ STATE AGENCY Cl COIROMTION ❑ LOGE AGENCY ❑ EEOEM4AGEN(Y ❑ INOMOUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE M,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROCESSOR IAN or EPA ID N a of TANK's ❑ I GAS STATION ❑ 3 FARM ❑ S OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to ineicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to md,cate ❑ PARTNERSHIP Cl STATE-AGENCY Cl CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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: 1. ❑ II. ❑ 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 a JURISDICTION aAGENCY## II FACILITY ID a a of TANKS at SITE m = IBJ c;2 O CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE A WRIT AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT A SUPERVISO"IMMICT CODE BUSINESS PLAN FILED DATE FI D ,C�.7\ '7 YES NO CHECK a PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT A BT: \ 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. •vim`\'1 FORM A(3-2-88), 16 li DATA PROCESSING COPY