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STATE OF CALIFORNI* WATER RESOURCES CONTROtBOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM �a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE ov r ^ MARK ONLY F—] I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM N LOS DSITE ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE z 10 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N ADDRESS lw�/ NEAREST CROSS STREET ✓G e ❑ PARTNEGEM ❑ FSTATE EDRIAGENLY (D 04 ,_Zlue� A OAPoPATIGI ❑ IDCA.AGENLY ❑ FEGEPAbAGENLY a�� ❑ INDrvIDUAL ❑ CWNIVAGENCY • lI i CITY NAME STATE CZIP CODE SITE PHONE M.WITH AREA CODE N 3 J+ TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ d PAOCESSON ✓Box ihINDIAN - EPA ID p N of TANN'a ❑ 7 GASSTATION 3 FARM 5 OTHER RESERVATIONNDS or AT THIS SITE[:] ❑ TRUST(ANDS 1:1 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) AHON N II .(CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE S IL 3 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME*IILAST,FIRST) PHONE At WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME loop CARE OF ADDRESS INFORMATION MAILING ETADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ILI 7s 7 ❑ CORPORATION 0 LOCAL-AGENCY 11FEDERAL-AGENCY .1 / ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME r STATE ZIP CODE PHONE 11,WITH AREA CODE J III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION. MAILING m STREET ADDRESS ✓B indAj.te ❑ PARTNERSHIP ❑ STATE-AGENCY ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY YG w� INDIVIDUAL ❑ COUNTY-AGENCY CRY NAME - STATE _ ZIP CODE PH E N,WITH AREA CODE 54S S- IV. LEGAL NOT (CATION 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 N JURISDICTION N AGENCYIN FACILITY ID R N of TANKS at SITE 3l l o CURRENT LOCAL AGENCY FACILITY IDN/ APPROVED BY NAME PHONE N WITH AREA CODE C 2a,2S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION C DE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED D '24so YES NO 4x NEC PERMI AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) I's- DATA PROCESSING COPY Y