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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PROGRAM V " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION � h ° , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Fy I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) 00 FACILITY/SITE NAME CARE OF ADDRESS INFORMATION A ADDRESS - NEAREST CROSS STREET V 04 10 oMga ❑ PARTNENSHIP ❑ STATE AGENCY .2?2 ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ❑ INGIVIOUAL Cl COUNttAGENCY CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 PROCESSOR ✓Box it INDIAN EPA ID x ESE ❑ 1 GAS STATION [:]3 FARM ❑ 5 OTHER TRUSTY ATION LANDS or F-1 Mol TANK't AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p 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 MAILING or STREET ADDRESS J Dox to mdN,.E. ❑ PARTNERSHIP ❑ STATEAGENCY 0 CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS JBaR to lndicale Cl PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE p,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. ❑ t,. ❑ 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 S AGENCY B FACILITY ID X N of TANKS at SITE = G CURRENT LOCAL AGENCY AACCIILIITY ID If APPROVED BY NAME PRONE Y WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LONCOOECENSUS TRACT F 8UPERVISOR-DISTRICT CODE BUSINESS PLLFiLED DATE FIL YEOICLO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE BY: I THIS FORM MUST BE ACCOMPANIED BY AT LEAST�OR MORE TANK PERMIT FORM 'B'APPLICATION(S), USS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) �, DATA PROCESSING COPY t