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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM NA': UNDERGROUND STORAGE TANK PROGRAM SITE al FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE "929 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Of 5 CHANGE OF INFORMATION ❑ 7 PERM OSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z 10 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) FACILITY/ NAME CARE OF ADDRESS INFORMATION ADDRESS �� NEAREST CROSS STREET ✓ mirAfBmit, 0 PARTNERSHIP D STATE AGENCY N Z 9.�/ D cowwTION Ill LOCAL AGENCY 0 RDEML�AGENCY CO ❑ INOMDIAL D COUNYAGENCY (D CITY NAME . STATE ZIP CODE SITE PHONE N.WITH AREA CODE W Q-r. CA TYPE OF BUSINE . ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box B INDIAN EPA ID # If of TANK'f ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTY ATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE 4 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 Wicale D PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY 0 INDIVIDUAL D 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 I ✓Bos Io inEicale 0 PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL D 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: 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(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION Al AGENCY# FACILITY ID R N of TANKS a1 SITE m � � I I I i6 CURRENT LOCAL AGENCY FACILITY ID N LAPPRE PHONE#WITH AREA CODE ZZ PERMIT NUMBER ]PERMITPROVAL DATEMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTNSUPERVI 0 -DINESS PLAN FILED DATE FIL7 '?rFYES NO�' / 2CHECK# PERMIT AAMOUNTSURCHARGE ARECEIPT# BY THIS FORM MUST BE ACCOMPANIED BY AT T(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON \V - 0 7