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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD FORMA': UNDERGROUND STORAGE TANK PROGRAM .o SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to AQ. COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA NTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Ste to irdvak ❑ PARTNERSHIP El STATE AGENCY ❑ T [I LOCAL AGENCY ❑ FEDERALAGENCY 7 Wyli[�Wy�� ' ION NIDUAL ❑ CDUNIY-AGENCY i CITY NAME 1 - ^ STATCA Z ODE�� dao 9 p�63REA COn�� TYPE OF BUSINESS J✓•✓❑.`-P TTR•WIBUIOORR ❑ 4 PROCESSOR ✓Box INDIAN EPA ID I n �� 0 ITANK'a 7V RESERVATION or AT THIS SITE ❑ 1 GASSTATION 3 FARM ❑ 5 OTHER TRUST LANDS ❑ O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(VST,FIRST) PHONE 4 WITH AREA CODE Lai o 1 _+I w. ao (03 --)013 NIGHTS:JAME(LAST,FIRS ) P ONE 4 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE D� II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION n i MAILING or STREET ADDRESS Be.✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE it,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET�RESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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. ler it. ❑ 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 N JURISDICTION 8 AGENCY W FACILITY ID 8 R of TANKS at SITE m as 7 1010 10101 CURRENT LOCAL r/�I A67Y FACIFACILITYILyI/ T APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBERG/ PERMIT APPROVAL DATE cS69— PERMIT EXPIRATION DATE LOCAs CODE CENSUS TRACT N SUPE R-DISTRICT CODE BUSINESS PLA(/FILED ❑ DATE FILED ^ L/A. 4 YES NO IA Oj1 CHECK t PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a 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. r . 1 FORM A(3-2-88) IIV,ItV/ DATA PROCESSING COPY