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JF CALIFORNIA WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PROGRAM 7 �o G C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER LY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION vr*N 10 ADDRESS NEARE TCROSS STREET ✓Sorb MbW ❑ PATRNFRSHP %EAGDO () S J(� N S AIZTIr 2 W ❑ LY7WMTIGN ❑ Tau AGENc F➢EW AGDILY ❑ PDMDw ❑ CaUM AGRNCY CITY NAME S-ree,�'D� STATE 21P C15- n � / S,0 ONES,WITH A8'—?REA R TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box'INDIAN EPA ID A JN (/,(� I' s RESERVATION or N o1 HIS SIa ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NA (UST,FIRST) PHONE k WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE � bwlj A I�s6 Z(7 —9 06 SA-K-e� NIGHTS: NAME(LAST,FIRS PHONE M WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE M WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S MAILING or STREET ADDRESS ' ✓Bo.to iftcate ❑ PARTNERSHIP ❑ STATE-AGENCY 60 CORPORATION 11LOCAL-AGENCY ❑ FEDERAL AGENCY W ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATER ZIP CODE �V / PHONE k.WITH CODE -7911 III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED)J/ (/f U Do NAME .� CARE OF ADDRESS INFORMATION /I MAILING or STREET AD SR ✓Bo.to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY A D A % (i O Lig El NDIIVIDUALION ❑ COUNTY-AGENCY 11 FEDERAL-AGENCY n CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE �7 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111. 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 R JURISDICTION R AGENCY F FACILITY ID R Rol TANKS at SITE CURRENT LOCAL AGENCY FACILITY)D APPROVED BY NAME PHONE N WITH AREA CODE L l' PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CO E CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED gO O YES NO CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT R BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERBuT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-813)