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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD A FORMW:: UNDERGROUND STORAGE TANK PROGRAM Z SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '� ,; 10 /, C/ COMPLETE THIS FORM FOR EACH ACILITY/SITE FMARK ONLY F-] 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 LOSER SITE —4 ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE g I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) pgoj FACILITY/SITE NAME - CARE OF ADDRESS INFORMATION r� G/7S G�©CF:Q1 ADDRESS NEAREST CROSS STREET ✓Bw lo,rocile 0 PARTNERSHIP 0 STATE AGENCY / } 0 CORPORATION 0 LOCAL AGENCY 0 FEDERALAGENCY ❑ INDIVIDUAL ❑ CAUNTYAGENCt CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 7/z CA 71>7;74/, ', %3 a TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box i DIAN EPA ID It Not TANK'L ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTYATION LANDS o ❑ AT THIS SITE Q� EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: ME(LAST,FIRST) PHONE N WITH AREA CODE DAYS,NAME(LAST,FIRST PHONE k WITH AREA CODE PA-06 D - 5� 00 e ��v,b Ze - if 3700 NIGHTS'. NAME(LAST,FIRS ) PHONE ft WITH—AREA CODE NIGHTS: NAME( T.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to intlicate Cl PARTNERSHIP Cl STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERALAGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME SG"o �( CARE OF ADDRESS INFORMATION Jt" MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ 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 R JURISDICTION R AGENCY K FACILITY ID K M of TANKS at SITE [� 4 0 d � L CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE N WITH AREA CODE P,104 - PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS SUPERVISOR-DISTRICT ODE BUSINESS PUN FILED ❑ DATE FILED ((DD// 31- YES NO i CHI PERMIT AMOUNT SURCHARGEAMOU T FEE CODE RECEIPTM BY:fix,/ 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(3-2-08) DATA PROCESSING COPY 0 L