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}.v T -... .v STATE OF CALIFORNI WATER RESOURCES CONTROROARD FORMA': UNDERGROUND STORAGE TANK PROGRAM SITE C FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Bw to 1 PARTNERSHIP ClSTATE AGENCY T / ❑ COHFOPATION 11LOCALAGENCY ElFEDEAALAGENCY Y� SPC Ji'P Cr/ - ✓ UCF so, INDMDUAL ❑ COU"-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE CA 9S�Je �v TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P SSOR ✓Bax if INDIAN EPA ID # ❑ I GAS STATION 3 FARM 5 OTHEfl RESERVATION o N of TANK's ❑ TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREAGODE R06e-,74 wg-83k-73,s�d' Su ., ,-e _-)nq - 3-/r-os" NIGHTS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME _ CARE OF ADDRESS INFORMATION Su .n-e Gr S _Z MAILING or STREET ADDRESS ✓Box toinoicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION A f /_L u A" - MAILING orSTREET ADORE 55 ✓Box tomicale ❑ PARTNERSHIP ❑ STATE-AGENCY ElCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY i O. 0x 9S' 1 (7 A Ci C.k S o, /?✓ ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE F 5 cu 1 . e /1 95` 3 1 a 1 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. ❑ III. 5-4' 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 N AGENCY# FACILITY ID# q /?#�o/TANKS at SITE l/ 7" / V 1 01 U 1 / CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE Ccf2R& ? PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED C& 1;? 2�O J -��'--1 YES NO CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: n 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. / ��FO M A(3-2-88) - 3 \ ( _c\ , DATA PROCESSING COPY . \