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Aw <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM ao <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ' o <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE `^��•o•�`" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 7 Cn <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) OD <br /> CJ1 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> e oC49W2!�_Mfll <br /> ADDNEAR <br /> ` NEAR STCRO STREET ✓ bigiulll 0 PARTNERSHIP 11 STATE-AGENGI <br /> f.0 S e ry �� O IYJI MTIDN 0 LOCAL,AGENCY 0 FEORSLAGENLY <br /> ❑ uaMDUAL ❑ CGUNTY-AGEN,X <br /> CITYNAME STATE ZIP CODE SITE PHONE I.WITH AREA CODE <br /> o" CA Q5 <br /> TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑ / ROGESSOR ✓Box if INDIAN EPA ID N <br /> RESERVATION or ❑ Sol SI <br /> ❑ i GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS AT TRISHIS SITE 2 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(IAST,FIRST) PHONE N WITH AREA CODE <br /> Y.l� <br /> t .26q-7417- 57 2 GI�-h/ar ✓oc - <br /> NIG TS: NAME ILAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> SAMr- as a 5'a—+t a6li j2 v —9HBA- <br /> ,215 1 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION <br /> 1Y1 10 <br /> MAILING or STREET ADDRESS �to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> O 7 SSS ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> o INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE <br /> k C4- 5 a 2�-qv8-zis <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> CAS z <br /> MAILING ar STREET ADDRESS ✓Box to,nd,cale 0 PARTNERSHIP 0 STATEAGENCY <br /> 0 CORPORATION C LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. Vf 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION S AGENCY S FACILITY IDS S O7 TANKS at SITE <br /> d 10 1 /T© i D <br /> CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE M WITH AREA CODE <br /> stead <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT P SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED ,L <br /> Q T 2 3,CTO YES ❑ NO ❑ SILS-/d% T <br /> CNECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTO BY: <br /> 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 O4 <br /> NL <br /> A(3-2-881 <br /> DATA PROCESSING COPY <br /> 1 <br />