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STATE OF CALIFORt" WATER RESOURCES CONT-M_ BOARD '`'• FORM `AN: UNDERGROUND STORAGE TANK PROGRAM n" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ami"^ o .) COMPLETE THIS FORM FOR EACH FACILITY/SITE `'�.oan`! MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITYfIAME CARE OF ADDRESS INFORMATION /SITE N in ADDRESS /-G NEAREST CROSS STREET ✓BypPbup ❑ YAG PARTY ❑ STATE AGRO LV ❑ G ❑ TEDOW ADDICT Y e i ,N AM , CITY NAME L STATE ZIP CODE SITE PHONE N.WITH AREA CODE clu r-- CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 1 PROCESSOR ✓Bud INDIAN EPA ID x E] I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION m ❑ J pl AT THHISIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE A 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 -/BO.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ 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 Ip indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ 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 k JURISDICTION N AGENCY N FACILITY ID N A,of TANKS al SITE CURRENT LOCAL ADEN Y FITRACT# ACILITY ID J APPROVED BY NAME PHONE J WITH AREA CODE PERMIT NUMBERPPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CESUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED D"9LEgYES NO CHECK M PESURCHARGE AMOUNT FEE CODE RECEIPT Y 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 i7z-BS) �c �Y DATA PROCESSING COPY i— P-01 BOX 2009 " 0 4 STIDICKTON, CA 95201 1 Penalties will be added after due date as shown: I) o I � L 30 days - 100% of mase Fee l I l l l l 1