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STATE OF CALIFORNIV WATER RESOURCES CONTR&OARD FORM `AI: UNDERGROUND STORAGE TANK PROGRAM � m SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION z COMPLETE THIS FORM FOR EACH ACILITY/SITE I L'9LIfOR�\P MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM 2 INTERIM P ❑ NTLY CLOSED SITE -4 PERMIT �q AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE � � I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) F-� FACILITY/SITE NAME CARE OF ADDRESS INFORMATION AG � � s� ply ADDRESS L NEAREST CROSS STREET '/ /\J /� 1 /. /A��IN l ,��Ala mtlrale ❑ LOCAL-AGENCY ❑ FEDERAL {{��✓✓ V (�V l7 -1FeA/ (i TU A ❑K INDAVIDUUAL' O �uN1V AGENq ❑ FEGEa+LAGENa CITY NAME STATE ZIODE S-ro(k7Q P� CA P CStd SITE PHONE p,WITH AREA CODE TYPE OF BUSINESS 2 DISTRIBUTOR n q PROCESSOR ✓Box if INDIAN EPA ID ft 1 GAS STATION 3 FARM L�/5 OTHER RESERVATION ora of TANK's TRUST LANDS AT THIS SITE I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS' NAME(LAST,FIRST) - PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) T w MIA" a/G-372-53/ / S/ /,/PHDfJTH gpEq CO E NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST FIRST)((//VV��, /v Hj I/H AREA PHONE p WITH AREA C00 �Z G ane II. PROPERTY OWNER I FORMATION & ADDRESS — (MUST BE COMPLETED) NAME �2 CARE OF ADDRESSPIFORMATION �l}NI�Ku /kUSTeo T /V ; GGE. cjo WA; �ovr# f�77o MAILING ar STREET ADDR S Q n ✓Box to indicate ❑ PARTNERSHIP O [ % 180 a ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY CITY NAME ❑ INDIVIDUAL Cl COUNTY-AGENCY STATE 21P CODE PHONE W,WITHAREA CODE /6- _5- Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME T CARE OF ADDRESS INFORMATION Q 5 �j� MAILING or STREET ADDRESS 11 STATE AGENCY .✓.lfax to intlicale El PARTNERSHIP R'T CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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. L::] it. 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) GATE LOCAL AGENCY USE ONLY COUNTY q JURISDICTIONA, AGENCY R FACILITY IDN It of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 12 2 $ � f rCHI TION CODE CENSUSrT�RACT a(� SUPERVISOR-0 STRICT C E BUSINESS PUN FILED DATE FILED 01 L 0 o 2O YES NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTA BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONI UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) ,ft DATA PROCESSING COPY