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STATE OF CALIFORNI0 WATER RESOURCES CONTRO 00ARD FORM IA': a �> UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P ENTLY CLOSED SITE ONE ITEM ❑ 1:12 INTERIM PERMIT ❑ q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ie I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �- ADDRESS ��/ Y� NEAR ST CROSS STREET ✓Ba Widirale ❑ PARiNERS4IP ❑ STATE AGENCY 60� V`r i I4–✓ L-I��LN ❑ CORPODIION ❑ LOCAAcouNTYGENCY 0 FFD�IAGEHCY CITY NAME STATE ZIP CODE SITE PHOGIE N,WI H A EAC DE S7llN CA 9 y0 y— a/ TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ d PROLESSOR ✓Box it INDIAN EPA ID N ❑ ❑ 3 FARM 5 OTHER RESERVATION or 1:1N of TANK'N I GAS STATION TRUST LANDS ATTHISSITE 0 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE � NA NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S� as Z MAILING or STREET ADDRESS x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME (31W4-e ` s —4CAREOf ADDRESS INFORMATION MAILING or STREET ADDRESS W Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 13COUNTY-AGENCYCITY 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 S JURISDICTION S AGENCY N FACILITY ID R R of TANKS at SITE 010 1 1 �6 0c/1 *0C) CURRENT LOCAL AGENCY FACILITY ID k GpIvl Fb APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RMIT EXPIRATION A LOCATION CODE CENSUSTryryRACT 2! 7/5 SUPERVISOR-RM lI�STRICTCODE BUSINESS PLAN FILED DATE FILED !/7� —1 u YES ❑ NO ❑ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 INFOF ORM A(3-2-88)