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STATE OF CALIFORA WATER RESOURCES CONTRL BOARD UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � h o a% t COMPLETE THIS FORM FOR EACH FA ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITS CHANGEOF INFORMATION 7 PER LY CLOSED SITE I I ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S3 C C I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) 4. FACILITY/SITE NAME /2�Lrof Oy/.� 57�/ CARE OF ADDRESS INFORMATION n/�keN I(/g��t ADDRESS NEAREST CROSS STREET ✓Bw10 odiak 0 PARTNERSHIP 0 STATE AGENCY L '/� ClC011N)RATION ClLOCA.AGENCY Cl FEDERAL AGENCY v - ❑ INDIVIOUAL Cl COUNTY AGENCY CITY NAME STATE ZIP COD SITE PHONE N.WITH ARE TYPE OF BUSINESS Z CA ❑ 2 DISTRIBUTOR ❑ 4 Pfl R ✓Box it INDIAN EPA ID # ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSTESEY LANDS ATION or ❑ AT HIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL Cl COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box tc indicale 0 PARTNERSHIP 0 STATEAGENCY Cl 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(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 K JURISDICTION R AGENCY R FACILITY ID N a o/TANKS at SITE 171 y7 � � a CURRENT LOCAL AGENCY FAgLF Y ID 4� APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT 11 SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED ❑ DATE FILE (OvT 3 YES NO CHECKII PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT X BY: THIS FORM MUST BE ACCOMPANIED BY AT IV(1)OR MORE TANK PERMIT FORM 'B'APPLICATION1 UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL% t S)FORM A(3-2-8 G R a, 8) DATA PROCESSING COPY