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rw.-„o.,�n�!°,7e.'K}en°°'.�r°..a}�R.�77�'�+ICY •Mlffii,�� ..�4 .d:..: � - - -. __. -- ( STATE OF CALIFORNIA► WATER RESOURCES CONTROL BOARD WP 5E T"F•s FORMW: . UNDERGROUND STORAGE TANK PROGRAMfi+ ° SITE '�� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' ` o l COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERM SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE zlif, I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/Sj "AME CARE OF S INFORMATION ADDRESS \ '7 NEA T CROSS STREET ✓Box toindicale ❑ PARTNERSHIP ❑ STATE-AGENCY F p ❑ CORPORATION ❑ LOCAL-AGENCY FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAM 1 TATE ZIP COD ITE PHCjNE#,WITH AREA CODE �r CA g -�:3 t I TYPE OF B INESS F—] 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID n RESERVATION or //►� $1 of TANK's GAS STATION [—] 3 FARM ❑ 5 OTHER TRUST LANDS El /4 AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERIIANCY CONTACT PERSON (SECONDARY) DAYS NAME(LAST,FIRST) PH �NEI WITH AREA CODEDA(Y�S. NA E(LAST,FIRST) PHONNV#WITH AREA CODE NI�rTS: NAME(LAST,FI ) ONE#WITH AREA CODE NIGHTS: f�NAME(LAST,FIRST) PHON #WITH AREA CODE J P — °7s ILA � II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NA r CARE Oy A DRESS INFORMATION MAILING oLSIBEFT ADDR,ESyd ° ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY //7 N /n��/ff ❑ CORPORATION ❑ LOCAL-AGENCY FEDERA GENCY � , J C.YI�L-� / ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY,PiAty1�� , y�J ,/ S1 fjT E� ZIP CODE � PHO ITH AREA CODE III. TANK OWNER INFORMATION(& ADDRESS - (MUST BE COMPLETED) S NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. II. ❑ 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 of TANKS at SITE [a] I I I I E[ I I LolI l `? I I o I o TTF�l CU T,,LyOOC�AL AGENCY FACILI YID# APPR�VEjD BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT ON CODE CENSUS TRACT# SUPERVISQR-,PIST ICT CODE BUSINESSYES PLANFILED NOq ILED CHECK# PERMIT AMOUNT SURCHAR E AMOUNT FEE CODE RECEIPT# 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 ONLY. F RM A(3-2-88) DATA PROCESSING COPY