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oZS3-�?D Q� STATE OF CALIFORNIP WATER RESOURCES CONTRIl%OARD FORM W: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION L COMPLETE THIS FORM FOR EACH FACILITY/SITE ^1110R MARK MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ELI I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 4 FACILITY/SITE NAME K CARE OFADDRESS INFORMATION / H" ADDRESS NEAREST CROSS STREET ✓Bo.k wim ❑ PAWN ❑ STATE-AGENCY 6// '. /,F/ // ❑ CORPORATION L AGENCY ❑ FEDERAL AGENCY 1101/ /(, ❑ INDIVIDUAL COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 21)-C K CA TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑4 PRO R ✓Bok if INDIAN EPA ID # RESERVATION or �J ,^,P N of TANK's ❑ 1 GAS STATION ❑3 FARM DlRfTHER TRUST LANDS ❑ % W Y"v ATTHISSITE , EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIG TS: NA (LAST. IRST) ONE It WITH AREA CODE NIGHTS: NAME(IAST,FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to iYd,..te ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE ft,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to ofti .V, ❑ 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: I. II. ❑ 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# AGENCY# FACILITY ID N N of TANKS at SITE E 10G 1 / s v CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE#WITH AREA CODE 7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCWO I CODE CENSUS TRACT M SUPERVISOR-DISTRICT ODE BUSINESS PUN FILED DATES FILED/ v^( YES NO ❑ / "`ILS O 0 CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 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 0 Y. FORMA(3-2-88) 46 DATA PROCESSING COPY