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%Ex�u9�k� r'YE STATE OF 'CALIFOR WATER RESOURCES CONTRBOARD FORM `AI: UNDERGROUND STORAGE TANK PROGRAMm SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o ;P COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION w&L.-rls uN oN 'Itp X5421 Oa ADDRESS ' I Lj.! NEA,RE1STGROS'SSTTRREET ✓Bmlomtlic#e 0 PARTNERSHIP 0 STATE-AGENCY ry 30 /�L I F L 1 V�N G ISA I✓w P-A ❑ NDIV WALON ❑ CGUNIYAGENCY AGENLY ❑ FEDERAL N STATE ZIP CODE SITE PHONE#.WITH AREA CODE CITU NAME - /I_7ey_d 2 A_ STac�KTor`l CA 5 1 Y V �T TYPE CP BUSINESS: ❑p OISTRIBIROR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's I� 5 OTHER RESERVATION or ❑ AT THIS SITE 161 GASSTATION ❑ 3 FARM ❑ TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE D1;� NIGHTS: NAM (LAST.FIRST) PHONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME QKIoLAL- oft, moo . MAILING or STREET ADDRESS ✓BBoox to intlicate Cl PARTNERSHIP CSTATE-AGENCY / G CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY GALI br- IA �(,p�f� ❑ INDIVIDUAL IT COUNTY-AGENCY CITU NAME STATE ZIP CODE PHONE p,WITH AREA CODE WAL_t\lLlT LR K G4 g45`l� 41S 9�S-� 7� 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME A � ABt / SAMA f� MAILING or STREET ADDRESS ✓Box to intlicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,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. ❑ 11. 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) A/_fL 1'r�, A�� DATE L,oRl P_ US-r) N LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATTJ'L,pD CODE CENSUSTTRAC�T# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED V! 1-2 , - `�/" ) -p YES [—] NO ❑ �Q 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($),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-81) /� DATA PROCESSING COPY