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STATE OF CALIFORNih- WATER RESOURCES CONTROL OARD UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F CILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C" a I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) CD FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS / NEAREST QROSS STREET ✓&xIo iMirale ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDENL AGENCY ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME C STATE CA �E ^� j�NE WITH AREA TYPE BUSINESS. ❑ 2 01 IBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p V,l/ `/ RESERVATION or #of TANK's �,A{a 1 GAS STATION ❑ 3FARM ❑ 5OTHER TRUST LANDS ❑ AT THIS SITE J EMERGENCY CONTACT PI&RSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(I-AST.FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMA ON & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION O LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRE - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION I MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE I ZIPCODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED F BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,IWD 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 If #of TANKS at SITE = = = 6o a X003 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE c Ce 3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS RACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES ❑ NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST 111 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNI FSS TWIS IS A CHANGE OF SITE INFORMATRD l Alh Y. FORM A(3-2-SB) /yl� DATA PROCESSING COPY \'\V.