SITE INFORMATION AND CORRESPONDENCE_CASE 1

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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMW: UNDERGROUND STORAGE TANK PROGRAM SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION }gym 1 G COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I.FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FAC ITY/SI E NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Box lordu* [IPARTNERsHp ElSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY S G {J i - ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME r STATE 711,CODE SETE P ONE N.WITH AREA CODE CA q-5,3ZO X38-J4v21 TYPE OF BUSINESS ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # k of TANK's ESEATION J1 GAS STATION ❑3 FARM ❑ 5 OTRER TRUSRVLANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS- NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE$1 WITH AREA CODE a NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION D / &u MAILING or STREET ADDRE ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY •� n ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAT 21P DE PHONE ,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ if. 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY fl JURISDICTION N AGENCY M FACILITY ID N If of TANKS of SITE in I co CURRENT LOCAL AGENCY FACILITY IDN O ED BY PHONE M WITH AREA CODE E:z4s 14 z 00 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 2 8 E1) G YES [—] NO CHECK sPERMIT AMOUNT SURCHARGE AMOUNT [FEECODE RECEIPT#_ BY: -- — Ll \ THIS FORD MUST BE ACCOUPANIED BY AT LEA'- TORE TANG(PERUIT FORM `6' APPLICATION(S), U!.^.:-_ '!$IS A CHANGE OF SITE INFORUATION ONLY. F♦ M A(3.2-88)