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STATE OF CALIFORNS WATER RESOURCES CONTROARD FORMW: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION h C COMPLETE THIS FORM FOR EACH FACILITY/SITE ea F RK 4..� MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) o FACILITY/S TE NAME f CARE OF ADDRESS INFORMATION ADDRESS ` 57-V} rJ % +✓ jNEARESTROSS STREET mloindiI ❑ PARTNERSHIP ❑ STATE-AGENCY E "" L INDW &T CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY❑ INDIVIDUAL ❑ COUNTY-AGENCYCITY NAME ZIP CODE SITE PHONE#.WITH AREA CODE S' -✓� I� �'7 `j�� TYPE OF BUSINESS' ❑p DISTRIBUTOR ❑ 4 P 0CEWA ✓Box if INDIAN EPA ID u ❑ I GAS STATION ❑ 3 FARM S OTHER RESERVATION or #of TANK's TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS, NAME(LAST,FI T] PHONE#WITH AREA CODE NIGHTS. NAME(LAS FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME WS CARE OF ADDRESS INFORMATION 5 MAILING or ST ET ADDRESS ,?/Xox to indicate ❑ PARTNERSHIP 1:1STATE-AGENCY ICJ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY VVVIII ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE I WITH A EA CODE S7n 4t3W--3'9l 20 -RX1/010 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET DDRESS ✓Box no indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 2' 0 � - ❑ CORPORATION El LOCAL-AGENCY El FEDERAL-AGENCY CITY NAME ❑ INDIVIDUAL ❑ CCUNTY-AGENCY S-70 aC STATE ZIP CODEPHONE p,WITH A��E�� IV. LEGAL NOTIFICATION AND BILLING ADDRESS -quf fhl'af CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II, 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 F(7) _6 I I I CrY7 I F—o I o CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE V4 9 2 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE BLED (� ,j(f/ �] ((J} YES NO �G I• CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# By. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) DATA PROCESSING COPY