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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 Io COMPLETE THIS FORM FOR EACH FACILITY/SITE FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"+ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ul cc FACILITY/SITE NAME CARE OF ADDRESS INFORMATION s -So^- ADDRESS NEAREST CROSS STREET ✓Bw 10l .18 ❑ PARTNERSHIP ❑ STATE AGENCY p C / ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ds S,�' ❑ INDIVIDUAL 1:1COUNIYAGENcr CITU NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE cS _/v L-k CA TYPEOFBUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P 0CESSOR ✓BO%it INDIAN EPA ID N RESERVATION or ❑ 1 GASSTATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ //M�C� 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 Lt res NIGHTS: NAME(LAST,FIRST) ''P''HO'1NE N WITH AREA COD NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE / /, Z/ II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S40 6.-ab on f- C A c"les MAILING or STREET ADDRESS ✓80x to i0oicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 13LOCAL-AGENCY ❑ FEDERAL-AGENCY 706 N - G OrrLd J�` 13INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHLOry E�N,WITH AREA CODE C?'4 gsao� _� 3/- O >S III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Ts M MAILING or STREET ADDRESS 4/Box to odicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ ORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY OIVIDUAL ❑ COUNTYAGENCY CIN NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS i CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# If of TANKS RI SITE 'kE% = oZ i 3 D OCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE iJI�L BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 30 0 3 as YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: AK MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIO ONLY. ) DATA PROCESSING COPY � ,,\\(J—�\`\J',