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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD f FORMA': UNDERGROUND STORAGE TANK PROGRAM �o SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 10 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITV/SI�NAME - �N c,, CARE OF ADDRESS INFORMATION AODRES u_® ,F NEAREST CROSS STREET leWI ❑ PARTNERSHIP ❑ STATE AGENCY N WOORATION 1:1 LOCALAGC [I FEERALAGENCY Co ❑ INONIWAL ❑ COUNTY-AGENCY 1�/ CITY NAME STATE ZIP CODE IiIITE PHONE#.WITH AREA CODE W CA �sao �B4 96,7 TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IO p #of TANK's SE ❑ I GAS STATION ❑ 3 FARM OTHER TRUSTYATION LANDS o ❑ • " on 1�7 ATTHISSITE llsi EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE � off. Ca-o9 9 91-&&?49 4 NIGHTSNAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE Sa,v - 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION rn N RDLD o lat MAILING TREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY S(� y/�.�� C ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ' Ii r, D r a- J�l ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME ^ STATE ZIP CODE PHONE#,WITH AREA CODE `J c,Kkh- co I Rsao 9 9Ifk-G44 III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME �` p d1,. CARE OF ADDRESS INFORMATION e "//yy L S 4: �I 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. X If. ❑ 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# D #of TANKS at SITE BE pp 0100101 CURRENT LOCAL AGENCY FACILcITY 1 N APPROVED BY NAME PHONE N WITH AREA CODE J PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO j CODE CES TRA T SUPERVISOR-DISTRICT CODE BUSINESSPELSAN FILED NO ❑ DAT FILE CHECK If PERMIT AMOUNT SURCHA GE AMOUNT FEE CODE RECEIPTN S 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 t ' FORM A(3-2-88) �" DATA PROCESSING COPY ...i /