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STATE OF CALIFORNIA- WATER RESOURCES CONTROMOARD J o. SE'`au 4' FORMA': °� � `s� UNDERGROUND STORAGE TANK PROGRAM z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE �"'•�e°'# MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE I—a, ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITECLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N N FACILITY/SITE NA CARE OF AD RE551NFORMATION ADDRESS NEARESt CROSS STREET D PARTNERSHIP D STATEAGENCY D D)R ORAiIl1N D Lock MENLY D REXTIALAGENLY I L D INDITUAL D WUNIYAGENLY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID# Bof TANK'# ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS RESERVATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(I-AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.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. ❑ Ill. ❑ 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 R AGENCY R FACILITY ID If S of TANKS M SITE E= CURB OCAL AGENCY FUI IDM APPROVED BY NAME PHONE N WITH AREA CODE GL PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DIS T CODEBUSINESS PLAN FILED DATE F L YES NO E] /3 CHE F PERMIT AMOUNT SURC RGEA OUNT FEE CODE RECEIPT# 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 INFORMATIONA Y. RM A(S-2-813) - - / `w DATA PROCESSING COPY xj