SITE INFORMATION AND CORRESPONDENCE

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j,. ; TATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �+ ORM 'A' y UNDERGROUND STORAGE TANK PROGR'4m.'�' `' h:,g ;"'`'':_' "m r ! SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o i COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE[TEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACIL /SITE NAME CARE OF ADDRESS INFORMATION AD RESS ^� NEA�R`EST CROSS STREET i�ft to Wcele ❑ PARFIIERS V ❑ STATEaN,'E O J9 IV I'1 !�r Al er O n E) ❑ Fl cr CITY NAME STATE ZIP CODE SITE PHONE R,WITH AREA CODE CA TYPE OF BUSINESS: 0 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA 10 0 ❑ 1 GASSTATION 0 3 FARM �S OTHER TRUSTVATION LAND$a � 0 of TANK'S AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA C00E NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate [3PARTNERSHIP CI STATE-AGENCY E] CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE k,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY . ❑ INDIVIDUAL. ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 0,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOYfi A1111101111A1111101111283Cs SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ 11. 0 111,❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE r r LOCAL AGENCY USE ONLY COUNTY N JURISDICTION 11 AGENCY A FACILITY ID N t3 of TANKS at SITE 1 ,3 1 Fa--Fo z) CURRENT LOCAL AGENCY FACILITY ID/ APPROVED BY NAME PHONE It WITH AREA CODE PERMIT NUMBER PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT• SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE LED D! a3 �O / Yrs ❑ No ❑ /1 CHECK I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE ' RECEIPT R THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-8) d �� 5, >r DATA PROCESSING COPY �.