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T STATE OF CALIFORNI.0 WATER RESOURCES CONTRO00ARD :sE a FORMA UNDERGROUND STORAGE TANK PROGRAM SITE O FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1 c COMPLETE THIS FORM FOR EACH F CILITY/SITE `'"•ow"—'� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE }-a ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) a) w FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 6 a �/ Co Aza ADDRESS NEAREST CROSS STREET ✓ nOaTs C PAATNERSHIP C STATEAGENLY '\ RPOPAMN C LOCALAGENCY C F DEM AGENCY o^[ (p C /_)f ❑ iNDM"L ❑ COUNTKAGENCY CITY NAME STATE ZIP CODESITE PHONE N.WITH AREA CODE CA ysaos Lao, g ? -os: TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 4 P SSOq ✓Box if INDIAN EPA 10 N RESERVATION arCC N of TANK'N ❑ 1 GAS STATION ❑ 3 FARM 6 OTHER TRUST LANDS ❑ N d AlS._ AT THIS SITE 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 C_o a ic/ u 9 / LtA-) NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE AI& u > IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ o indicate ❑ PARTNERSHIP C STATE-AGENCY t/ q0 , / Q l CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY —7 ! /Clj! C INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE 5 1vc-k PHONE N.WITH AREA CODE CA sav e III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ to Inpicaie Cl PARTNERSHIP C STATE AGENCY ��qq ,pp CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY . V is C INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE -5frJL/C /-vn - 1 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ if. ❑ Ill. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT. APPLICANT'S NAME(POINTED&SIGNATURE) DATE 777 LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY M FACILITY ID M N o/TANKS at SITE 3 9 O o / 7 3 Ll D o 1 o] / CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE III LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODEBUSINESS PLAN FILED DATE FILED U / 13 S _ YES ❑ NO [] S�d-?/ CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B' APPLICATION ), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. I S DATA PROCESSING COPY r � j/