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STATE OF CALIFORNIP WATER RESOURCES CONTRONOARD "f FORMA": UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ~m COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7F3EMgyENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (J 2 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME 5 / —,T.J CARE OF ADDRESS INFORMATION /9 fl Lt 1 r! B�V f ADDRESS )� � /�'Tpp� NEAREST CR OSS STREET ✓BmWirdi0 c0i 0 PARTNERSHIP 0 STATE AGENCY v (N /V ° /, / 0 COWDRATION LOCALAGENCY 0 REDERALAGENCY (/� vv L 0 INDMOWL 0 COUNTY AGENCY CITY NAME ,J STATE ZIP CODE SITE PHONE A.WITH AREA CODE -1/ -'/✓rj O i TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 CESSOR ✓Box if INDIAN EPA ID # N 3 FARM 5 OTHER �o I GASSTATIORESERVATION or - #of TANK' ❑ ❑ 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 Al WITH AREA CODE NIGH76. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box to indicate Cl PARTNERSHIP 0 STATE-AGENCY Q I U / 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY El INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITHfRE CODE a 9ea� lsa�/ Za9 -y�X- yv- Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATEAGENCY0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY Cl INDIVIDUAL 0 COUNTY-AGENCY CITU NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVB ADORESB 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# GENCY# FACILITY ID# #of TANKS at SITE m 0191 T6 1 513 CURRENT LOC AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE DA� }N.i012, PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATEFILE YES NOIV' fvC CHEC PERMIT AMOUNT SURCHAR EAMOUNT FEE CODE RECEIPT# BY: /i/ lff 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 FORMA(3-2-88) • � ,