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STATE OF CAL I FO R N Ill WATER RESOURCES CONTROSOARD �F F,P T �5 •.Euv[t�'•.�F•. FORM ` : UNDERGROUND STORAGE TANK PROGRAM o SITE LDa FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � COMPLETE THIS FORM FOR EACH FACILITY/SITE C9•^tijFO FN\P F ARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION MANENTLY CLOSED SITE NE ITEM2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (611 N 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 00 FACILITY/SITE NAME r. CARE OF ADDRESS INFORMATION IVIA ADDRESS Cf NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 4 Ilj�,® CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY (;dAJ"�� INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME �L��I' STATCA ZIP COBS— � SITE PHI NE N,WITH AR�� / TYPE OF BUSINESS: 2 DISTRIBUTOR El PROCESSOR I/Box if INDIAN EPA ID p /(�S sy RESERVATION or ' / n/� If of TANK's / 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS ❑ /v (rV AT THIS SITE 411111 0 EMERGENCY CONTACT PERSON(PRIMARY) EMERG NCY CONTACT PERSON(SECONDARY) DAYS: NAME ST,FIRST) . PHONE 4 WITH AREA CODE DAYS: N ME(LAST,FIRST) PHONE'N WITH AREA CODE 13_1 IA Del A NIGHTS: NAME(LAST FIRST) PHONE 4 WITH AREA CODE NIGHT : NAME(LAST,FIRST) Pi 4 WITH AREA CODE o �'3 - �Z,S"s11A j A 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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: 1. 4?---11. ❑ 111. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVE BY 7c(Igit PHONE#WITH AREA CODE C.0 3 �/l PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L' / ( d k LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO(Q-' O CHECK# PERMIT AMOUNT SURCHARGE AMOUNT 7E CODE RECEIPT If 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. FORM A(3-2-88) 5 �U • DATA PROCESSING COPY