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, ATE OF CALIFORNIA WATER RESOURCES CONTROIOARD ;st -ok >E ,-ORM 'A': �ate- . �>n, UNDERGROUND STORAGE TANK PROGRAM ," " SITE G1 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o COMPLETE THIS FORM FOR EACH F TTY/SITE °'��Fo?�`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EI'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"a ONE ITEM ❑ 2 INTERIM PERMIT ID AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S3 c"00 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) F+ FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET Dwle ❑ PARTNERSHIP ❑ STATE-AGENCY RATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY OIVIOUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE c� CA :5'20 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PR q ✓Box if INDIAN EPA ID p RESERVATION or #01 TANK'e o ❑ 1 GASSTATION ❑ 3 FARM OTHER TRUST LANDS ❑ �� AT TRIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(LAST,FIRST) / PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 17 r) Gt /U O NIGHTS: NAME(LAST,FIRST( PH NE 4 W H AREA CODE NIGHTS: NAME(LAST,FIRST( PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME �.y.+ CARE OF ADDRESS INFORMATION c7 � . MAILING or STREET ADDRESS I/Bo indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ PRORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OFADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bo.t dicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ COPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY DIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4.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# JURISDICTION# AGENCYIN FACILITY ID# If of TANKS at SITE [iZ IO6I a IjEail oa I v � CURRENT LOCAL AGENCY FACILITY ID N ^ APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER C ZZ r//f,�PERMIT p PEL9` APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIL 3 ko 3d YES NO ❑ c),- CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:el I La THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMA ION ON FORM A(3-2-88) DATA PROCESSING COPY