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of. STATE OF CALIFORN WATER RESOURCES CONT R BOARD 4 FORMW: UNDERGROUND STORAGE TANK PROGRAM =and m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT p CHANGE OF INFORMATION 7 PERMANENTLY CL D SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE y I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FA.CR ITY/SITE NAME CARE OF ADDRESS INFORMATION S ADDRESS NEAREST CROSS STREET ✓Box brac& ❑ PARTNEf iP ❑ STATE AGENCY G ❑ COIfOMTION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY .�l / F L/[� J `i n C LE ❑ N OMDUAL ❑ COUNTY AGENC! C I Y NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE CA TYPE OF BUSINESS 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID N _ RESERVATION or Mol TANK'S FI 1 I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT 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 Jeri S'3S ,) -7Sv — NIGHI S NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAIL ING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY Q ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE �GhfG' III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAW CARE OF ADDRESS INFORMATION Mau ING ui STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ASOVS ADORN"SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. P" if. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPI ICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY [PE JURISDICTION If AGENCY 0 FACILITY ID 0 0 of TANKS of SITE ull'i IC/ ILI AGENCY FACILITY ID N APPROVED BY NAME PHONE WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUSTRACTN SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILEDDATE fIIED YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT• BY: 1 HIS FURM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMAJK NLY.