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STATE OF CALIFORNhc WATER RESOURCES CONTR008OARD ;z` ''^ ` FORMA': UNDERGROUND STORAGE TANK PROGRAM l , s, XL SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� COMPLETE THIS FORM FOR EACH FACILITY/SITE rr1. °"rnonxl" 4 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATIONNTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ Y AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE a 4m III 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) �, iiiia, FACILITY/SITE NAM ARE OF ADDRESS INFORMATION ADDRESS NEAREST CR�.OSS STREETT/� fin/ ✓BM IOiMrale ❑ PARTNERSHIP ❑ STATE AGENCY APCl CORPO11 LOCAL AGENCY �� f •-'�� ` "�+" •"& �v/ ❑ NDNIWRAL11IGN ❑ 001 AGENCY iEDEAAL AGENCY CITY NAME STATE 2 PCO�� SITE PPHHON 0 a(l �AAREA COD 0 CODECAI76 Z TYPE OF BUSINESS' ❑ 2 DISTRIBUTOR ❑ ROCESSOR ✓Box if INDIAN' EPA ID p IT of TANK's ❑ 1 GAS STATION ❑ 3 FARM IT TRUSESETYLANDSATION O ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS E( T,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST( PHONE#WITH AREA CODE 5O rj NIGHTS. NAME(LAST,FIRST) PHONE AT WITH A EA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS L / x to V indicate El PARTNERSHIP ClSTATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIPOOOE PHONE J!,WITH AREA CODE C-I94-3 3 s' 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME — CARE OFADDRESS INFORMATION MAILING or STREET ADDRESS ✓pox to in0ci le ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#.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: L EVI. ❑ 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# JURISDICTION It AGENCY# FACILITY ID It If of TANKS at SITE m = = o oo / CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONCO3CENSUS TRACTM✓0 SUPERVIS`QR2- 11 I T CODE BUSINES YPSNFILED NO ❑ DATE CHECK# J( PERMIT AAMMODUNTSURCHARGE AMOUNT FEE CODE pECEIPT# BY: 1 THIS FORM MUST BE ACCOMPANIED BYAT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UPI ESS THIS IS A CHANGE OF SITE INFORMATION ON \vAI) FORM A(3-2-88) DATA PROCESSING COPY