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STATE OF CALIFORMi WATER RESOURCES CONTR`-eBOARD f FORM FA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION C' COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWALPERMIT 0-,"CHANGE OF INFORMATION ❑ 7 PERMAN YCLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE QA ou li I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME a CARE OF ADDRESS INFORMATION rYl z / e T G "/ N ADDRESS NEAREST CROSS STREET C�rltridXab ❑ pp1iRlEAGHIp ❑ STATE AGENCY CONPOMTION 0 LOCAL-AGENCY 0 FEDEM AGEN py '"/� ❑ INDWIDU41 0 CCLUJY-AGENLY Vry� CITY NAME STATE ZIP ODE ITE PHONE Al.WITH AREA CODE 34p qK4I:2�v� CA:77 -512 aQ - E TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓BOX R INDIAN EPA ID #r�II ��.� w� 0 of WS ❑ 1 GAS STATION ❑3 FARM fff THEA RESBEO A ION or ❑ �1/t+ KC ATTR SS SITE / EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE GAR az (aoq y�G- a w ao GG-47 y NIGHTS: NAME(LA FIRST) P!12WI AREACODE NIGHTS: NAME(LAST,FIRST) PHONE# ITH AREA CODE SC&yrul a QI - 174 1 II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE At,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S u ✓Vt e- C MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGFNCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHCNE#.WITHAREACODE 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. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. I APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY i COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE am = = 10101 / 101a101C% OU l CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE Zf- O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-0111�STrRICT CODE BUSINESS PLAN FILED DATE FILED L./ 3 f(�' Q YES NO CHECK PERMIT AMOUNT SURC ARGE AMOUNT FEE CODE RECEIPT• 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. _ FORMA(32-RB) S �..- DATA PROCESSING COPY �+'