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STATE OF CALIFORNIA�'r WATER RESOURCES CONTROL ` BOARD FORM ' Q ,. . ; /� UNDERGROUND STORAGE TANK PROGRAM SITE (_!' FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION :. COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE17ANEUILYCLOSED SITE N ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE \ C 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) LD FACT TY ITE NAME CARE F ADDRESS INFORMATION V A ADDRESS NEAREST CROSS STREET ✓ONbiii ❑ PARTNERSHIP ❑ STATE AGENCY ��60APORATION IDLOCAL AGENCY ❑ FEDERAL AGENCY S INOIVIGUAI ElCOUNTYAGENCY CITU N E STATE ZIP CODE SITE PHONE ,WITH AREA CODE_ CA l Z Z7 Zoe I Z'I'S3�� TYPE -BUSINESS. 712 DISTRIBUTOR F__] 4 PROCESSOR ✓8oxYit INDIAN EPA ID# /` AS STATION ❑3 FARM ❑ 5 OTHEfl TRUST ATION0' ElCf }[�0 a/Q 7 ATTHIS SITE 06 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#W TH q CODEDAV ME(LAST,FIRST( PHO ITR AREA CODE Z 3 A ,4 NIGHTS: NAME( IRST) PHONE#WITH AREA CODE NIGH76:)NAME(LAST,FIRST) PHONE If AREA CODE II. PROPERTY OWNER INFORMATIO & ADDRESS — (MUST 1JB(/E'E COMPLETED) ld NAME CARE OF ADDRESS INFORMATION 5 1A MAILIN TREETADDRES 13Elp Box to Indicate PARTNERSHIP STATE-AGENCY O , �I g ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY U ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME • 4 STATE ZIP CODE PHONE#,WITH AREA CODE CA I 131 S 111. TANK OWNER 1 ORMATION &ADDRESS — (MUST BE COMPLETED) NAME S CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Bae to indicate ❑ PARTNERSHIP ❑ STATE AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE 21P 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. ❑ 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# #of TANKS at SITE uEl I d a 111 (_2z bon CURRENT LOCAL AGENCY FACILITY ID# AVPp V D Y NAML PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE `/ PERMIT EXPIRATIO DAT LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 72-0 YES � NO CHEC PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 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. F p2 8B) 'uAv/ Y �,,,� DATA PROCESSING COPY � j.