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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD o, eEx`a� ref W FORMW: UNDERGROUND STORAGE TANK PROGRAM z .� SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,o C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5<5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I.aI. ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ONO FACILITY/SITE N MCARE OF ADDRESS INFORMATION Q OE (Ge, 0rr� ADDRESS NEAREST CROSS STREET ✓EOA IoiMiple Cl PARTNERSHIP ❑ STATEAGENLY �A Q ❑ RATION 11LOCAL AGENCY [IFEDERAL-AGENCY V f— INDmpUAL ❑ COUNNAGENCY ''. CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE ask- ji CA ZOS N I TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box N INDIAN EPA ID N N of TANK'N RESERVATION or ❑ I', ❑ 1 GAS STATION ❑ 3 FARM THEfl AT THIS 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 ac -e( 21 -Y63-6330 SmpI 14M, 2 — ?v-31,69' NIGHTS: NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE e IJ 2 - 63-6 a - 231-31,69 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ttt� CARE OF ADDRESS INFORMATION xAl.� MAILING or STREET ADDRESS ✓Box tojntljcate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ 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 S MAILING or STREET ADDRESS ✓Bax W joaicate ❑ PARTNERSHIP Cl 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)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ Ill. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AN C APPLICANT'S NAME(PRINTED&SIGNATURE) DATE — l LOCAL AGENCY USE ONLY COUNTY N JURISDICTION Al AGENCY N FACILITY 10 If N of TANKS at SITE M] = = 1010l DDD CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE 11 PERM NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [LOLCATIONCODECENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILEYES [] NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ONLY. `QRM A(3-2-58) - ' b.r DATA PROCESSING COPY ano