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STATE OF CALIFORNIP WATER RESOURCES CONTROL OARD .1N FORMA`: UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 L COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ q TLY ISED SITE N ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE V q I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) m FACILITY/SITE NAME "raCARE OFADDRESS INFORMATION ' NZG JU kitd ADDRESS NEAREST CROSS STREET Be✓ to imdoxie 0 PAIRNERSHIF Cl STATE AGENCY 1,^ A,yI 1 n ❑ CORPORATION ❑ LOCAL AGENCY 0 FEDERALAGENCY INDIVIDUAL 0 COUNTY-AGENCY CIN NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA I4Jr 3/ TYPE OF BUSINESS: ❑2 OISTRfBUTOR ❑ 4 PROCESSOR ✓Box i1 INDIAN EPA ID N ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER RRUSESETYLANDS or ❑ AT SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#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 indicate ❑ PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,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. ❑ IL ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION Is AGENCY# FACILITY ID# It of TANKS at SITE m = = `lsi 01 (--) 1 0 1-0 CURRENT LOCAL AGENCY FACILITY ID# �� APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER SS A•V/ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONQODE CENSUS TRACT p## SUPERVISryryOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Z 3 O� 7 L YES NO p.�l4) CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: r THIS FORM MUST BE ACCOMPANIED BY AT LEAS§O0 MORE TANK PERMIT FORM `B'APPLICATION(S),�SS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2881 �- 301 0 DATA PROCESSING COPY