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STATE OF CALIFORNI9 WATER RESOURCES CONTRAOARD FORM NA': _ b� UNDERGROUND STORAGE TANK PROGRAM me Z - m 1c SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o P COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ i NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANI N ED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE cc F%; I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Ca FACILITY/SITE NAMECARE OF ADDRESS INFORMATION I J�/AJ 7 ADDRESS I� A FQ /Al q-RL NEARES ROSS STREET ✓t'mbNdrNe ❑ PANINBMNP ❑ SfATEdGENLY / 0 COFL OPATDN 0 LOCAL-AGFND' 0 FEDEPMI.-490 d , Q x 5W (� 0 INDNDDN 0 COIINIYJ,GE#LY CITY NAME / STATE ZIP CODE SITE PHONE N-WITH AREA OOD n CA 9 /�J/� GQ3 Y TYPE OF BUSINESS: ❑2DISTRIBUTOR ❑ ROCESSOR ✓Box W INDIAN EPA IDN It of TANK'# RESERVATION or ❑ AT THIS SITE / ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS EMERGE CONTACT PERSON(PRIMARY) EMERGENCY CT PERSON (SECONDARY) qx,Q PHONE#WITH AREA CODE NAME(LAST,FIRST) I'HONEp WITH AREA CODE S: NAME(LAST,FIRST) W Iff r j--r IA)(n'�(f ) Df./4v `1 g2—Sa 9� PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME ST,FIRST) II. PROPER Y ER INFORMATION & ADD S (MUST BE COMP ) NAME F ADDRESS INFORMATION MAILING rSTREET RESS o ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 0 'IC CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY CO, B I/ 0 INDIVIDUAL 0 COUNTY-AGENCY ATE ZIP CODE PHONE N,WITH AREA CODE CITY NA Ill. TANK O ER INFORMATION & ADDRESS — (MUS BE COMPLETED/)/ CARE OF ADDRESS INFORMATION NAME A.4 MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE CITY NAME 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 N JURISDICTION# AGENCY# FACILITY IDN #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE C I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PCH�CK*?" DEENNSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINES1PLAN FILED NO ❑ DATE FILED PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY.. IS 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. / RM A(3-2-88) / I 1 I • 3 DATA PROCESSING COPY 1