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STATE OF CALIFORNO WATER RESOURCES CONTIN BOARD FORM NA': UNDERGROUND STORAGE TANK PROGRAM SITEC, FACILITY/SITE, INFORMATION and/or PERM APPLICATION C9ll(O RN\P COMPLETE THIS FORM FOR EACH FAC /SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANE G7 OSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME c CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET 0 � MR4TIx GN Q i"�AGENCY 0 FEDERAL ANCY GE cr 33 /�- Scr>h�s D INDWIDUu ❑ DuuxnA6B+LY CITY NAME STATE ZIP CODE SITE PHONE It.WITH AREA CODE CA /532 .?&F-W.4 -Sv3� TYPE OF BUSINESS ❑ 2 DISTRIBUIDfl ❑4 P ESSDR ✓Box it INDIAN EPA ID N - It of TANK's ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUSTVATION LANDS or ❑ I AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(I-AST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE Lbave 009 -9y> sY3 NIGHTS: NAME(LAST.FIRST) PHONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION .SQ G4S4 A a I,, © aY ✓�c ( S a(/L).j MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY Cl FEDERAL-AGENCY L D INDIVIDUAL D COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME ` CARE OF ADDRESS INFORMATION ,I C Sa h,& �� .& � ea MAILING or STREET ADDRESS to indicate Cl PARTNERSHIP D STATE-AGENCY / CORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE �s sz e/as CTI yDD�to a/.3 -a6 7 -J `>r7/ IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY41 JURISDICTION N AGENCY k FACILITY ID M Al of TANKS at SITE \ O o l 7 3 1 01 01 0 1i CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE 59N7✓- 0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED l.tiU 0 / ,)j G0 2.?__3 YES [] NO E] / 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(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.r. \ FORMA(3-2-68) • � (Jl \�j