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��yl•OF�.J.,+ STAT"OF WATER RESOURCES CONTRO OARD ly kuk kwr'•�E•. FORMW: UNDERGROUND STORAGE TANK PROGRAM _gym SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ISJ COMPLETE THIS FORM FOR EACH FACT /SITE "`�""'P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 7 I CC I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET A�✓?�zI'dicale ❑ PAFTNERSHIP ❑ STATE AGENCY % r }'�GORPORA71ON ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY s�1 171 INDIVIDUAL ❑ GOUNTY-AGFNCY "- CITY NAME STATE ZIP CODE E PHO E#.WITH AREA CODE #� /L' CA S rF I L TYPE OF BUSINESS: F12 DISTRIBUTOR F-1 EPA ID 4 PROCESSOR ✓Box if INDIAN #of TANK'S 5 OTHER RESERVATION or AT THIS SITE ❑ 1 GASSTATION 0 3 FARM ❑ ❑ TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NST.FIRST) PHONE#WITH AREA CODE LAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST, IRSTy PHONE WITH AREA CODE NIGHTS, AME{ ST, IRST) PHONE#WITH CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME { CARE OF ADDRESS INFORMATION ,,D/M/49 MAILING or ST EFT ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ` ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME .......... ZIP CODS �� PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADORESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. ❑ If. 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# AGENCY# FACILITY ID# #of TANKS at SITE L I j 1-/ Ig-10- b] Lo aEl I 1 -1-1 _t CURRENT AGENCY FACILITY ID# APPfi0YE0 BY NAME PHONE#WITH AREA CODE PERMIT NUMBER ]_PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ? YES NO ❑ " CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: l THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONI UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORMA{3-2-85} ' J �, DATA PROCESSING COPY