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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMW: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1A L COMPLETE THIS FORM FOR EACH FACILITY/SITE 1-�1 MARK ONLY � 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE z ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT K6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W �MM ADDRESS NEAREST GROSS STREET ✓BcR to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY W C ❑ CORPORATION ❑ LOCAL-AGENCi ❑ FEDERAL-AGENCY r ❑ INDIVIDUAL ❑ WUNTY-AGENCY CITY NAME �_ STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS ❑ 2 DIS IBUTOR d PROCESSOR ✓6ax of INDIAN EPA ID p RESERVATION or #of TANK's 1 GAS STATION D a FARM 5 OTHI TRUST LANDS � AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME{LAST.FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY _ ❑ INDIVIDUAL © COUNTY-AGENCY _ 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: 1. 0 IL III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ARID CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SIJODE CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA C PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATE C DE CENSUS TRACT# SUPERVISOR-DI TRICT CODE BUSINESS PUN FILED DATE FILED YES NO 12- z Z 'CHECK# PERMIT AMpUHT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEI"T!1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S). UNLESS THIS IS A CHANGE OF SITE INFORMA FORM A(3-2-88) DATA PROCESSING COPY rT