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_ ._ STATE OF CALIFORN11 WATER RESOURCES CONTROBOARD FORMW: : UND€RGROUND STORAGE TANK PROGRAM i no m SITEt�j FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION t ; COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLYI 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 cr) 00 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FAGILI�TE yANE y � CARE OF�DRESS INFORMATION �JI ADORE N ST CROSS STREET Tmi laindirale ❑ LOCAL-AGEN ❑ STATE-AGENCFEDERAL-AGEY li'COAPOAAL ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ IN01410UAL ❑ COUNTY-AGENCY CITY NAM ' STATEVCC�v/ HO E#,WITH AREA CODE CA TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR FV-] OCESSOR ✓Box it INDIAN EPA ID # RESERVATEON or �� // R of TANK'a E] Y GAS STATION ❑ 3 FARM HER TRUST LANDS El 1"O AT THIS SITE r EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DA S: NA (LAST,FIRST PHONE#WITH AREA CODE DAYS' RME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 4 PHgNE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHO #WITH AREA CODE . 011Jt,F 7?.Alb .s A II. PROPERTY OWNER INFORMATION & ADDRESS -- (MUST BE COMPLETED) NA CARE OF A RESS INFORMATION MAILING or STREET ADDRESS ✓ x to inchoate El PARTNERSHIP ❑ STATE-AGENCY PORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITYNAIyE SC _ ZIP OC �0 H # WIT AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE/COMPLETED) NAME GARS QYDRESS INFORMATION /A /'�`+/ MAror/`rPEET ADDRESS ✓ to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ` / � CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY L ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME + STATE ZIP CODE PHO E#.WITH AREA CODE 104 n I vo A IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. [C] IL ❑ 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 E I I I�] I I I 1 0 CURRENT LOC*AGENCY FACILITY ID k AWgVED�Y AM PHONE R WITH AREA CODE f ! � ([YrFy� !f +S� PERMIT NUMBER PERMIT P OY DATE PE MIT EXPIRATION DATE l � LOCATION CODE CENSUS TRACT N SUPERYI R-DISTRICT CODE BUSINESS PLAN FILED DAT FIL /�'�,/ �� YES � NO � L 00 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# Y: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORMA 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) DATA PROCESSING COPY 0