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n . STATE OF CALIFORIA WATER RESOURCES CONTROL BOARD FORMA": UNDERGROUND STORAGE TANK PROGRAM �o SITE �LITY/SITE, INFORMATION and/or PERMIT APPLICATION ' COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 11�5 CHANGE OF INFORMATION ❑ 7 P LY CLOSED SITE •Q ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) •CAS FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W ADDRESS /i NEAR TCROSS MEET ✓9m IYW le ❑ PARTNEASHIP ElSTATE AGENCY r Tf�. (may // LlCORMFUHION 11LOCAL AGENCY 11FEDERAL AGENCY / ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREACOD CA �' Z- i TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR -/'Box if INDIAN EPA ID a RESERVATION or N of HIS SI ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) t • � /� PHONE N W�AREA/CODE DAYS: NAME(LAST,FIRST) � 0� PHONE M WITH CODE NIGHTS: NAME(LAST,FIRSK) PHONE H WITHVl/AAHLA CODE NIGH NAMEGLAST IRSTT)) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME O /h� CARE OF ADDRESS INFORMATION U I MAILING o1 STREET ADDRESSI 11✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY „ ( ❑ CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY 1� 'A INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE �./ PHONE N,WIT EA CODE III. TANK OWNER INFORMATION &ADDRES —/(MUST BE COMPLETED) oy L NAME C !-/w//w &!5 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bax toindicate 0 PARTNERSHIP ❑ 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)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ IL ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE CURRENT LOCAL AGENC AGILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE X15 1 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVIS R-DISTRI CODE BUSINESS PLAN FILED DATE FILED 3 Z YES NO ❑ ✓� IF CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY:� THIS FORM MUST BE ACCOMPANIED BY AT LEASVOR MORE TANK PERMIT FORM 'B'APPLICATION(S), SS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-8S ORMS/� DATA PROCESSING COPY D 3