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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMA': UNDERGROUND STORAGE TANK PROGRAM o ilbo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE o""O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE D I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE AME CARE OF ADDRESS INFORMATION ADDRESSYn�. NEAREST CROSS STREET ✓Bwb MbaA D PWNMW ❑ STATE AGENCY 1 11 3 U I 0 oowmT*N 0 IOGLAGENcf G FELE0.4L.AGDO Q } �Yt. . D IWIVIDIAL D CMM AGENCY CITY NAMESTATE ZIP CODE SITE PHONE N.WITH AREA CODE CA $ao.S TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P ESSOR -/Box it INDIAN EPA ID Al N of TANK4 ^ RESERVATION or ❑ AT THIS SITE d� F] 1 GAS STATION E] 3 FARM OTHEfl TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE N 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 toinCkate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERALAGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH AROVB ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ if. ❑ 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 R JURISDICTION P AGENCY R FACILITY ID M R of TANKS N SITE " DO I U CURRENT CAL AGENCY FACILITY ID N APPROVED BT NAME PHONE P WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOQ N CODE CE S T11ACT.k SUPERYISOR-DIITRICT CODE BUSINEBE PLAN❑FIED NO ❑ DATE FILED OHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: 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 ONL5 FORM A(3-2-88)