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STATE OF CALIFORNI'E- WATER RESOURCES CONTROwSOARD FORMAN: UNDERGROUND STORAGE TANK PROGRAM SITF FACILITY/SITE. INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE Of ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY FACILITY/SITE NAME ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY CARE OF ADDRESS INFORMATION ❑ INDIVIDUAL ❑ COUNTY -AGENCY 10 STATE ZIP CODE PHONE N, WITH AREA CODE PERMIT EXPIRATION DATE LOCATION CODE NEAREST CROSSSTREET I/ BMW Foo? ❑ PARTNETGHIP ❑ STATEAGENU ADDRE DATE FlO CHECK Y o WwOM o ❑ LoC wAfi(Y ElFEWM AMM 73 — Co. FEE CODE ElINJINOJAL ❑ WUNTY.AGRICY CITY NAME BY(D STATE CA ZIP CODE SITE PHONE N, WITH AREA CODE SDCot70 TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ "PROCESSOR ✓ Box if INDIAN EPA ID N Y of TANK'Y F -1I GAS STATION ❑ 3 FARM F-15 OTHER VATION or ❑ AT RESERLANDS 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) PHONE N WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE Of ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CURRENT LOCAL AGENSCLfACILITY ID Y CURRENT ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APPROVED BY NAME PHONE Y WITH AREA CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE N, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CURRENT LOCAL AGENSCLfACILITY ID Y CURRENT ❑ CORPORATION 0 LOCAL -AGENCY ❑ FEDERAL AGENCY APPROVED BY NAME PHONE Y WITH AREA CODE ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE N, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WNICN ABOVE ADDRRB SHOULD BE USED FOR BOTN LEGAL NOTIFICATION AND BILLING: I. ❑ 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 1 Orel A(:FNCV IJAF ONLY COUNTY Y 3 l JURISDICTION R AGENCY R [�]I FACILITY ID Y R of TANKS BI SITE I / I ?-1310 1 1 1 ;?- CURRENT LOCAL AGENSCLfACILITY ID Y CURRENT APPROVED BY NAME PHONE Y WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR -DISTRICT CODE BUSINESS RAN FILED YES NO ❑ DATE FlO CHECK Y PERMIT AMOUNT SURCHARGE AMOUNT Co. FEE CODE BY(D THIS FORM MUST BE ACCOMPANIED BY AT LEAST (I) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLT I FORM A (3-2-Be)r