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e STATE OF CALIFORNIK WATER RESOURCES CONTROt BOARD a FORMAA': UNDERGROUND STORAGE TANK PROGRAM SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 713 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANE OSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1411 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NgME CARE OF ADDRESS INFORMATION i chi ros Ole ger � ct r, e c- h ' rv; ADDRESS ^ ' (� / NEAREST CROSS STREET ✓&Rwineuk PARTENSNIP El STATE AGENCY /�,/(, ❑ COfROMTOR ❑ LOCI-AGENCY ❑ FEDERAL AGDa ❑ REARM ❑ WANT!-AGENCY CITY NAME STATE ZIP CODE SIDE PHONE N.WITH AREA CODE CA C 3 TYPE OF BUSINESS'. ❑ 2 DISFRIBUTOR F—] 4 PROCESSOR ✓Box if INDIAN EPA 10 NESEN W TANK'F ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSTTLANDS or ❑ 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 A NIGHTS: NAME(LAST.FIRST) PH NEN WITH EA CODE NIGHTS: NAME(IASF FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION D iQ, Yv"CC. h w MAILING of STREET ADDRl,/1'.A11 ESS ^' I ✓Box to indicate 1:1 PARTNERSHIP ❑ STATE-AGENCY Vl El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE S In r✓ C6 9 Sao Cao d 01 Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING ar BTREET ADDRESSv I ✓Box Io Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE Al,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH AHOY[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 R JURISDICTION B AGENCY* FACILITY ID R M of TANKS at SITE Q� 16 1 n I `f Ias a 01 CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE F WITH AREA CODE r+ a PERMIT NUM ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L1 N CENSUS TRACT P SUPERVISOR• ISTRICT CODE BUSINESS PIAN FILED DATE F LED �3 R YES [:] NO CHECK PERMIT AMOUNT SURCHARGE 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 FORMA13-2-SS) (^