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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM PA': UNDERGROUND STORAGE TANK PROGRAM = " ' SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E�r5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ Z INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE S3 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CAR OF DDRESS INFORMATION 0 Anl ADD-RREESSS�2 _/ NEAREST CROSS STREET ✓Ilwlo oloOr 0 POTM79W 0 SIATEMPIC( DORKWor(Clo n/ 13 I ng O Lw�u+rr-A AGBO13 CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE cz � CA 95206 — TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box B INDIAN EPA ID N ❑ I GAS STATION ❑ 3 FARM ❑ 5 OTNEA TRUSTYLANDS ATION eT ❑ X of TAP AT THIS SI EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE a o'i'. Z09- 4r , NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION tk 0� otic a MAILWGor STREET ADESS -/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ,O ' DRC 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY O 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE `'a k-k � l 520 - - 3 757 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME a5 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE 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: 1. ❑ IL III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE E 2 LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY R FACILITY 10 N N of TANKS at SITE EE EEE CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS"TRACT• BUPERV180Z CODE BUSINESS PLAN❑FILED NO ❑ D11TE�I.ES�� CHECK f PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 6 LBY4 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 (3-2-M)