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OI". STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD a FORMW: UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PE APPLICATION mo `P COMPLETE THIS FORM FOR EACH F LITY/SITE MARK ONLY ❑ L NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION no!? ✓, (Groep ENCY ADDRESS NEAREST CROSS STREET ❑ Aax PON [I PARTNERW [I STAR LOCAL AGENCY O RMEM AGENCY a33 3 3 r Jn mor INDNIDUAL ❑ COIMYAGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE IN/C CA 0 C9 / " TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ /PROCESSOR ✓Bdx 111NDIAN EPA ID N If of TANK'N ESE ❑ 1 GAS STATION ❑ 3 TARN ❑ 5 OTHER TRUSTYATION LANOS dr ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE er z� sy - NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME 7CARE OF ADDRESS INFORMATION 'Q r✓�e - .5 L.— MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION $q G s —7- MAILING MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA'70E IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: - F, 11. ❑ 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 M JURISDICTION B AGENCY R FACILITY ID R R of TANKS M SITE lololvIoT77 lololoH CURRENT LOCAL AGENCY FACILITY ID ti APPROVED BY NAME PHONE N WITH AREA CODE G a PERMIT NUMBER PPROVAL DATE PERMIT EXPIRATION DATE LOCATION CCODE CENSUS TRACT BUPERVI80R-D18TRICT CODE BUSINESS PLAN FILED DATE FILED YES NOPERMIT AMOUNSURCHARGE AMOUNT FEE CODE RECEIPT N BY: 0 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 ONLT- FORM A(3-2-88)