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/.� -a^rr. ,- r.. ter. rv,•,- - T _'�„^' .,. nwYVR�f�iA'+A+nn:1!�rw' 'T+P:T_.'",I ._.,...�. ...rx"1^^^�.ylp+ ^ ---�..—�.�..� .. STATE OF CALIFORNIX WATER RESOURCES CONTRBOARD ;9` ' r`E FORM 'i UNDERGROUND STORAGE TANK PROGRAM V �a S!M FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,; z COMPLETE THIS FORM FOR EACH ACILITY/SITE `'�r�oaN" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA Y CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 —4 N I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAMECARE OF ADDRESS INFORMATION RESS ADDN REST CROSS STREET ✓BOMB idM ARTND)SIP ❑ STATE-AGENCY A n n I(/ ❑ LUA RON ❑ LOCAL-AGENCY ❑ FEDSk AGENU AKA' YY�� ❑ NiI ❑ COUNTY-AGBILY CITY NAME STATE ZIP CODE 9TEPHO E p,W1�q��, p�D CA CO( 4 (p TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Boz iI INDIAN EPA ID # k of TANK's / ❑ 1 GAS STATION ARM ❑50THER TRUSRESTYLANDS TION or Elt W �'"�� ATTHIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION i Q C MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION O LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �Q MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODEPHONE#,WITH AREA CODE 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IDN #o1 TANKS at SITE U 17 701 OF I CURRENT L ALA N Y FA ILJJ'Y ID k APPROVED BY NAME PHONE#WITH AREA CODE PERMITNUMBER r/}I'r/') PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACnTT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED q.�J r a -5 a YES ❑ NO & (5 CHEC PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BP 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, 1I� FORMA(3-2-88) 1I- DATA PROCESSING COPY