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STATE OF CALIFORNIP WATER RESOURCES CONTROROARD i Ptd T f FORM `b': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIOW -� o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION In7 PEE�MANGPLAYCLOSEDSITE r ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE NO I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) C FACILITY/ [/ {,</Mq E y � CARE OF ADA@ESS INFORMATION ADDRESS NY�`!'^w�'l/�� // NEAR/•`T'/C/RO/ry15 TR BIO El nPARTNERSHIP ❑ STATE RAAGENCY El CORPORATION ❑ LOCALG 13 INDIVIDUAL El CoLN AGENCY GY CITY NAME �A , STATCA ZI ODF� _j� SITE PHONE;WITH AREA CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID #ESES !T/ ❑ It of TANK's 1 GASSTATION ❑ 3 FARM ILKOTHER TRUSTYLANDS ATION o ❑ A/AA AT THIS SITE GI/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAV - NAME VjST,FIRST)x _ PH NE#WITH AREA CODE' AVS: NA E(LAST,FIRST) PHON-E�ITH AREA CODE Qf- V164 — NIGHTS'. NAME(I-AST.FIRST) P NE WITH AREA CODE NIGHTS AME(LAST,FIRST) PHONE WITH AREA CODE a SA SA sQ II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) N CARE OF A KESS INFORMATION MALING or STREET AD RES ^ b` ✓Box to intlicale ❑ PARTNERSHIP 1:1 STATE-AGENCY I/i{,/. ElCORPORATION ❑ LOCAL-AGENCY CV 11 INDIVIDUAL 11COUNTY-AGENCY ERA GEN CITU NAME , STATj# ZIP CODE J� �q, I AREA CODE 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE CCCOMPLETED))Jr( r[/nGl/ (a, NAME SLA CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to lntlicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 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. ❑ 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) GAT LOCAL AGENCY USE ONLY COUNTY# JURISDICTION Of AGENCY# FACILITY ID It If of TANKS at SITE [flil = = IG o 2 D CURRENT LOCAL AGENCY FACILITY 10# APP OVED B NAM PHONE#WITH AREA CODE U l�li o PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT k SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED DATE/FILED i6 YES ❑ NO KY f( 2 0 CHECK# PERMIT AMOUNT SURCHARGE A OUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEASIOR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMr1TION ONLY. ORM A(3-2-88) 1 I It DATA PROCESSING COPY \ y