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STATE OF CALIFORNO* WATER RESOURCES CONTROBOARD FORMA': UNDERGROUND STORAGE TANK PROGRAM �o SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SI ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 10 FACILITY/SITE ME CARE OF ADDRESS INFORMATION lkr En-ter ADDRESS N REST CRO %/✓ IoiMiW@ ❑ PAAiNEASHIP ❑ SiAiE�AGENLY N S757PC?C �v enbi n d 0� CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCYCo INONIDUAL ❑ COUNW AGENCY CITY NAMEQ l STATE ZIP CODE SITE PHONE p,WITH AREA CODE S_fV cA 6;09 7?-5 TYPE OF BUSINESS ❑ 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA M aa1 Wont_ ❑ 1 GAS STATION ❑3 FARM I!aOTHER TRUSTVATION LANDS or ❑ AT HIS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) OAVS NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE (fir an Grlai aa47�-55�/ CSS ,- NIGHTS: NAME(LAST, IRST) QPHONE a WITH AREA CODE NIGHTS'. NAM AST FIRST) PHONE It WITH AREA CODE S )v" <I- 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME K- COR p CARE OF ADDRESS INFORMATION MAILING or STREETA RESS -/Dd<t0 indicate ❑ PARTNERSHIP 11 STATE-AGENCY DA CORPORATION ElLOCAL-AGENCY E3FEDERAL-AGENCY 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE P ONE q.WITH AREA CODE III. TANK OWNER INVORMATION &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 a,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. ❑ It. 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 P JURISDICTION R AGENCY R FACILITY ID It II of TANKS at SITE E I DC C) o ® / CURRENT LOCAL AGENCY FACILITY 10 V APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# DE CENSUS TRACT M SUPERVISOR-DIS RICT CODE BUSINESS PLAN FILED DAT FILE YES NO ❑ 31 PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k B I \ 1 I 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. \1� FORM A(3-2-881 0 DATA PROCESSING COPY •