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_, STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD t '"` ?"° FORMA': °:�°�'4'' �; UNDERGROUND STORAGE TANK PROGRAM = � " SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z �a COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•aa�`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL ITE N ONE ITEM ❑2INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑ fi TEMPORARY SITE CLOSURE QI cn I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) r. FACNUWR NAM jv CARE_ FjDDRESS INFORMATION /N/,/ ADDRE / NE T CROSS STREET 11 PARTNERSHIP ❑ STATE ASENCY / RATION ❑ LOCALAGENC! ❑ FEDERA1AGEI CY INDIVIDUAL ❑ CDUNIY-AGENCY CI STATE Z DDF IT PHO N ITH AR ACODE CA S(� 2* TYPE OF SINESS: F—] 2 DISTRIBUTOR E]4 PROCESSOR ✓Box if INDIAN EPA ID A ESEA It of TANK's 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTtLANDS ATION o ❑ " AT THIS SITE/.") EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA E(LAST.FIRST) PHONES WITH AREA CODE DA5 AE(LAST,FIRST) PHON H AREA CODE NIGHT�M (LAST,FIRST) 3,W1(NIE N WITH AREA CODE NIGH S: NAME(LAST,FIRST) PHONE TH AREA CODE � a`y'� S II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILI JSTI1�///])RE DDRESS >� ✓Box to lntlicM. 11PARTNERSHIP El STATE-AGENCY S ❑ f.ORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY �{�)��//�� INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMGy✓ " - ' ` " ' STA ZIPC DF�� PHONE WITH AREA CO E 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)S 7 NAME/ CARE OF ADDRESS INFORMATION MAILINA o,STREET ADDRESS ✓Box to indicsoe ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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 DON LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. 11 111.❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE EHI I e 10 1� CURRENT LOC�GENCY FACT ITY ID# APP V D BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PESAIIT APPROVAL DATE PERMIT FXPIRAJOND TE LOCATION CODE CENSUSTRACT* AgSUPERVI O DISTRICT CODE BUSINESS PLAN FILED DATE ILE ( YES NO CHE M 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 INFORMATION ONLY. ORM A(3-2-88) POW DATA PROCESSING COPY 'AW