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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM ' SITE UNDERGROUND STORAGE TANK PROGRAM ' �^ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z �. 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE i OnN� MARK ONK ONLY 1 NEW PERMIT []3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 2 INTERIM PERMIT 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE ® �PERMANENTLY CLOSED SITE I`+ 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 0 cn FACILITY/ ITE NAME Iw /J/Ar bas EL C EOF DRESS INFOR AT ON/ vI ADDRESS T T I LJIAJ I r]7. P(/-`T�l I C NEAREST ROSS STREET ✓gPglxcw ❑ PA�,� ❑ FATE AGENCY� ON ❑ LOCAL.AGENCY 11 MA094C YI1" /O NpWCITY NAME 001 AGENCY M! STATE ZIP CODE SITE PHONE A.WITH AREA CODE N CA K TYPE OF BUSINESS: ❑2 DISTRIBUTOR 4 PROCESSOR ✓ � Box if INDIAN EPA ID p I GAS STATION D 3 FARM S OTHER RESERVATION or ❑ -/ / N of TAI IPN TRUST LANDS (�1/N/ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) (VQ . 1 PHONE p WITH AREA CODE DAVS. NAME(LAST,FIRST) PHONE p WITH AREA CODE JV rs 3 - z00 NIGHTS: NAYE(LAST,FIRST) ,/� PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) / � � [//C 52L_0 O / .� PHONE p WITH AREA CODE II. PROPERTY OWNER IN OR 1 IOU III ADDRESS — (MUST BE COMPLETED) NAME I CAR FAD RE INFORMA ON a V , mill e(soN r(� /ylJ MAILING or ST ET ADDRESS ✓Bo omil El PARTNERSHIP STATE-AGENCY RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTV-AGENCY CDY NAM / A ZIP CO ONE p, ITH AREA CODE m z /s 8-OW I TANK OWNER INFORMATION a ADDRESS — (MUST BE COMPLETED) NAME CARE F ADDRpSS FORMATION SAn-tE �s 6 l�ur�e MAILING or STREET ADDRESS ✓BoxI oicete ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ ORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY VIDUAL ❑ COUNTY-AGENCY CITY NAME S ATE ZIP CODE PHONE N,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 8 SIGNATURE) PATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS N SITE m = OD t CyRRENT L LOCAL AGE CILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE K pjj PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LC CENSUSTRACTN SUPERVISOR-DITRICT CODE BUSINESS PLAN FILED DATE FI D YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIFT0 BY: '1 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 0 ` \ ¢ORM A(3-2-88) - ' - \\\\WTI �d DATA PROCESSING COPY