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or-. STATE OF CALIFORNIO WATER RESOURCES CONTRO00ARD W FORM NA': UNDERGROUND STORAGE TANK PROGRAM �e SIT 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 PER SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S� I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION rA LSO r S ADDRESS NEAREST CROSS STREET ✓Bm bi'dCBk PARTNERSHIP ❑ STATE AGEN E. ❑ COWGRITION ❑ LOCALAGENCY ❑ FEDERALAGENCY Cl INDMDUAL ❑ CGUNTY AGENCY CITY NAME 97 �n C� STATE ZIP C53 3 SITE^l OPHONE� N,WITH AREA C E im TYPE OF BUSINESS: ❑ 2 DISTRLIBUTLOR_ ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID k /��TyL,,Q, O� If f TAN` OQ ❑ I GAS STATION ❑ 3 FARM a OTHER TRUST LANDS RESERVATION or ❑ `+ - — AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) HONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE Al,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BECOMPLETED) NAME CARE 017ESS INFORMATION MAILING or STREET ADDRESS ✓Be.to in bate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPOR ON ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE Z CODE PHONE It,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 ILLING: 1. ❑ II. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KN NkvLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DAT LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY* FACILITY ID N N of TANKS at SITE = = = 03 CURRENT LO.CAk AG NCY FACILITY LQ N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION C DE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F D 4ONLY. a 2 �UYES NO � fJACHEC N PERMIT AMOUNT SURCHARGE AMO NT FEE CODE RECEIPTN BY:THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIO FORM A(3-2-88I c xoo ` cl