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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ' ^ FORM IA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FAC ITY/SITECL .Id. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 4f91 I. FACILITY/SITE INFORMATION 8 ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION S ADDRESS NEAREST CROSS STREET ✓BuMnex3N D PARTNERSHIP D STATE AGENCY D v D UARPORATION D L(KALAGENCY D ROENL#GENCY D NOMDIN D CDANTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS'. ❑2 DIST OR ❑4 PROCESSOR I ✓BOX it INDIAN EPA ID N ❑ 1 GAS STATION ❑ 7 FARM ❑ 5 OTHER RESER LANDS or F-1 N of TANK'N AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(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 II WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CANE OF ADDRESS INFORMATION MAILING oY STREET ADDRESS ✓BOX to Ina tale D PARTNERSHIP Cl 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 III. TANK OWNER INFORMATION b ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADORESS INFORMATION MAILING m STREET ADDRESS ✓Boa W Indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY _ CITY NAME STATE ZIP CODE PRONE p,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ 11. ❑ HL❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID M N of TANKS At SITE CURRENT LOCAL CY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE "7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES LOCATION CODE CENSUS TRACT# 7� NO 31Z/ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 71�RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1t^O MORE TANK PERMIT FORM 'B'MPLICATION(S), UNLF"S THIS IS A CHANGE OF SITE INFORMATION ONE . FORM A 13-2-68) SAP