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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMW: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMA ENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CRO STREET ✓&a bb5®le D PAAINEASIP Cl surEAGDa 7 y Elrtm ODWMDON °o LOCALACWVY ENCY D FEDEW 1GI ICY CITY NAME 7TF ATE ZIP ODE SITE PHONE N,WITH AREA CODE G CA Q TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 1 S$OR -/Box if INDIAN EPA ID F RESERVATION or If of TANK' ❑ 1 GAS STATION ❑ 3FARM THER TRUST LANDS ❑ ATTHISS% (0 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,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 b WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION rP ' 10 MAILINGor STREETADORESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY a� D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE �aO III. TANK OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box to indicate D PARTNERSHIP D 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 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WNICN ABOVE ADDRBBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 111. ❑ 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 E JURISDICTION N AGENCY E FACILITY ID M N of TANKS a1 SITE " 2E D � a3 © o CURRENT L AGM PICY FACJLITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L CENSUS TRACT N SUPERVMOq-018TRICT CODE BUSINESS RAN FILED DATE MUD 3 1 � YES ❑ NO O PERMIT AMOUNT SURCRARGE AMOUNT FEE CODE gECEIPTN BY: if 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. FORM A(3-2-88)