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STATE OF CALIFORNI10 WATER RESOURCES CONTROROARD FORMA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT R-5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 1:12 INTERIM PERMIT 1:14 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE (a T I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ffo-rry rYaIi m u ra ADDRESS Q NEAREST CROSS STREET ✓Bmbidrale 0 PARTNERSHIP Cl STATE AGENCY 9 31 Pe l ti ✓ R 0 WIPOILITION 0 LOCAL-AGENCY Cl FEDEI AGENCY 0 INDMDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE f}cc+�y'o CA 95.Zl v TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID N 0 of TANK's ❑ 1 GASSTATION ❑ 3 FARM ❑ 5 OTHER TRUSTVATION IANDS or ❑ ATTHISSITE 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 I< m l+arr ao 314 5 NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE Al WITH AREA CODE IL PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME C CARE OF ADDRESS INFORMATION J MAILING or STREET ADDRESS ✓Box to ind,cate D PARTNERSHIP D STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY D FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP 0 STATE AGENCY Cl CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. ❑ If. ❑ 111.❑ 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 R JURISDICTION M AGENCY N FACILITY ID R R of TANKS S1 SITE 3q1 oa I civ 1 va CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME �� PHONE N WITH AREA CODE 1'V19 KAMgb PERMIT NUMBERPERMIT APPRO PERMIT EXPIRATION DATE LOCA E CENSU N UPERVI TRICT CO BUSINESS PLAN N❑FILED NG ❑ DA FILED 33i CH CK# PE IT UNIT SURCHA ISAMOU FEE CODE RECEIPT# BY: yy� T ORM MUST BE ACCO BY AT LEAST(1)OR MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATIO ONLY FORMA(3-2-8 ( •