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• loi�� STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ".. FORM FA': UNDERGROUND STORAGE TANK PROGRAM Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : Ic ',r - COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 2T 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 50 00 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) Ln FACILITY/ ITE NAME CARE OF ADDRESS INFORMATION EtA ADDRESS NEAREST CROSS STREET ✓Bona idixate ❑ PARTNERSHIP ❑ STATE AGENCY LCl 00FARDRATION �"CDGALAGEND C FEDERALAGEND S #_\pY1 Cl INDWIIDUAL C COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE M,WITH AREA CODE CA R� o Lag 3la`6 � 73S TYPE OF BUSINESS: 2DISTRIBUTOR4PROCESSOR -/Box if INDIAN EPA IDN Not TANK' O I ❑ RESERVATION or ❑ AT THIS SITEs ❑ 1 GAS STATION E] 3 FARM E6TBEF TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE it WITH AREA CODE DAYS: NAME(LFIR AST, ST) — PHONE it WITH AREA CODE +1!i J-a r Zpg3rn4 5 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST PHONE it WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION (_1 O f Lod i MAILING or STRE ADDRESS ✓Box to indcate C PARTNERSHIP Cl STATEAGENCY C CORPORATION B LOCAL-AGENCY C FEDERAL-AGENCY 33 L3 t4 Cl—,y, (, Ck 0 fL C INDIVIDUAL C COUNT(-AGENCY CIN NAME STATp ZIP CODE PHONE p,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME J f CARE OF ADDRESSINFORMATI L� VY MAILING or STRE ADDRESS ✓Box to indicate C PARTNERSHIP El STATEAGENCY -� C CORPORATION &LOCAL-AGENCY Cl FEDERALAGENCYAL 2- ( (,3 �I Yl 2. S C INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE U odt' C.- RSaA4 333 1,,'? U IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE Do ( 3� o00 1 ! CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESSI,P S N FILED NO ❑ DATE F� "i 2910 L4 CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M w�l(yJ 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. ^, FORM A(3-2-88) • • `v\ DATA PROCESSING COPY