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STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD W. a UNDERGROUND STORAGE TANK PROGRAM �d SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION } � COMPLETE THIS FORM FOR EACH FAC TY/SITE ""°s^"�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT r CHANGE OF INFORMATION ❑ 7 PER TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � ' 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NA CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Do b olm ❑ PARTNERSHIP ❑ STATE AGENCY �r�p./ }7 ) ❑ CORPOMTION 11LOCAL AGENCY ❑ FEDERAL AGENCY 11INDrvIWAL Cl COUNP(AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE 1 Tc (k- CA �� TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i1 INDIAN EPA ID a RES❑ I GAS STATION ❑3 FARM E:] 5 OTHER TRUSTYATION ❑LANDS G R of TANICa AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(I-AST,FIRST) PHONE If WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#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 ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING of STREET ADDRESS ✓Be.to indicate ❑ PARTNERSHIP Cl STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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. ❑ 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 N JURISDICTION N AGENCY M FACILITY ID N Mol TANKS Bt SITE mI I I / � o ee�?I<0 1 4:1, / CURRENT LOCAL AGENCY FACILITj'IDN . / APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER I( V NPERMI APPROVAL DATE PERMIT EXPIRATION DATE [CHECK OCATIO�ODE CENSUS TRACT N, SUPERVISOR-DIST11 CT CQDE BUSINESS P 5 N❑FILED NG ❑ DATE F E j/ O PERMIT AMOUNT SURCHARGE AM3OUNTT C FEE CODE RECEIPT N 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 INFORMATION ONI,Y.-- FORM A(3-2-88) 0 0 1\J\)