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rwEr -.-' „*`-'�„'.a'M"-,t�sF'�r,,,r r, z .,�,.�fir.,• 'Ff. '(r�ij'+k., STATE OF CALIFORNfll WATER RESOURCES CONTR IOARD /,y' 'i"""x"'ryF` i A : UNDERGROUND STORAGE TANK PROGRAM "mo FORMo SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r YGI'% COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ERAIA,UFAI LY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE (� p C3 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CAREff ADDRESS INFORMATION REST C OSS STREET ✓BoaIo-ndirale ❑ PARTN€RSHIP Ll STATE-AGENCY RD E S �, /, ❑ CORPORATION ❑ LOCAL-AGENCY ERA AGE CIO (J//V�' "!f. ❑ INDIVIDUAL ❑ COUNTY-AGENCY _ —4 CIT!NAy{E ST E J„{RE � NE IF.WITH "4 j` GA TYPE OF BUSINESS: F-12 DISTRIBUTOR Ll4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's 5 OTHER RESERVATION or ❑ A AT THIS SITE 6ASSTATION ❑3 FARM ❑ TRUSTLANDS y'll EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS NAM LAST,FIRST) HONE#WITH AREA CODE NI HTS. NAME(LAST, RST) ONE N WITH AREA CODE NIGHTSN (LAST.FIRST) �P7NE#WITH AREA CODE S S A � II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF DRESS INFORMATION MAILING or S FET ADDRESS ✓Box to indicate El PARTNERSHIP ❑ STATE-AGENCY 5 7J�ly ❑ CORPORATION ElLOCAL-AGENCY F ERA AG NCY El INDIVIDUAL ElCOUNTY-AGENCY CITY NAM v STATE ZIP CC DE NE7A, 17ti AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME 5w CARE OF AX777 MAILING or S'JRJET ADDRESS ✓Box to inoieate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCYFEDERA GENCY El INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME w ;t STA ZIP COD. � PHO WITH AREA CODE IyY1, epi IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Er If. ❑ 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 d b CURRENT LOCAL AGENCY FACILITY ID# APPROVED BYNAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPER ISOR-DISTRICT CODE BUSINESS PLAN FILED D T ILED YES © NO CHEC # PERMIT AMOUNT SURdHARdE AMOUNT FEE CODE RECEIPT# B THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS 11 A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-86) ve - DATA PROCESSING COPY :.