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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM =o <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICA 'm< I© <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 15-a 7 <br /> MARK ONLY ❑ NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> to <br /> I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) w <br /> W <br /> FACILITY/SITE NAME .f/ 1q CARE OF ADORES' " '-l'" '-N <br /> c bG'F{ta+rt'O//1PlS Eleas_ Crum <br /> ADDRESS CROSS STREET ✓ mlo0 PARTNERSHIP 0 STATE-AGENCY <br /> CORPORATION LMAGG 13 FEDERAL AGENCY LY172-0myffmAj Ale, <br /> E0 IND O <br /> CITY!NAME'�n��'fb� STATCA ZIP CODE SITE <br /> e7 —PHONE p,WITH 112-EA CODE <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID N Z 2 IT ofTTAANK'a, 3 - <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUSRESET LANDS or ❑ U N AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS' NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S Vei�,A,S m '?W-. //23 <br /> NIGHTS: NAME(LAST,FIRST) OrHONE a WITH AREA CODE NIGHTS. NAME ST,FIRST) PHONE N WITH AREA CODE <br /> S t�A s ,1I- YS'-og! u^/ <br /> 11. PROPERTY OWNER INFOR MATION & ADDRESS - (MUST BE COMPLETED) <br /> NA]"° - - CAR OF ADD SS INFORMATION <br /> HfC_kINboFNam rs�t� �,(nl <br /> MAILING or SI REET ADDHESL�O ✓/Rox to indicate 0 PARTNERSHIP ❑ STATE-AGENCY 0 <br /> 'CORPORATION 0 LOCAL-AGENCY FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITYSTAT ZIP PHONE p,WITH AREA CODE <br /> NAME C <br /> t2,0 t jzd?_?918'_/123 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME c CARE OF ADDRESS INFORMATION <br /> I V <br /> MAILING or STREET ADDRESS ✓Box 10 intlicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I.vw� it. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTYN, JURISDICTION N AGENCY X FACILITY ID K K of TANKS at SITE <br /> p1 11119 1 lR_ � OOOO <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE M WITH AREA CODE <br /> a-- <br /> C <br /> PERMI NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> DE CENSUS TRACTM SUPERVISO -DIST111CT CODE BUSINESS,$N FILED NO DATE FI ED �, <br /> 23 � �a ❑ ❑ I PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11%OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-08) _ <br /> DATA PROCESSING *_00110"i+�COPY <br /> �` <br />