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STATE OF CALIFORNIAO WATER RESOURCES CONTROL OARD FORM W: UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED MARK ONLY NEW PERMIT N ONE ITEM 2 INTERIM PERMIT 4 AMENDEO PERMIT 6 TEMPORARY SITE CLOSURE Oh a) I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) p FACILITY/SITE NAME �+ "I CARE OF ADDRESS INFORMATION ADDRESS /W INDIVIDUAL NEAREST CROSS STREET 0 OOWO N ElLom-AGBILY ❑ FEDEWAGENO ❑ INDIVIDUAL ❑ WIINII'AGENCV CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA IDN #01 TANK's I GAS STATION 3 FARM RESERVATION➢r ❑ AT THIS SITE 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(IAST.FIRST) PHONE#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 ✓Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION Cl LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE 21P 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 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY 0 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. D it. 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 1016 17F CURRENT LOCAL AGENCY FACILIT ID APPROVED BY NAME �p PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APP OVAL TE RMITEXPI TIONDATE (� L LOCATION CODE CENSUS TRACT M SU PVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FIL D YES NO [:] `O CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# B THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),�SS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) • ) DATA PROCESSING COPY