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T STATE OF CALIFORPA* WATER RESOURCES CONAAARD rr FORMW: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l " o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � Ln I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACILITY/SITE NAgqE CARE OF ADDRESS INFORMATION fM S?�rn S Ockx ADDRESSNEAREST CROSS STREET Io 1 0 PARTNERSHIP 0 STATEAGENCY „ ^ �� CORPORATION 0 LOC&AGENCI 0 FEDERAL AGENCY ' �/f ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME1 STATE ZIP CODE SITE PHONE p,WITH AREA CODE S- Ot (/�o N CA 570 / 2-01-141-3311 TYPEOFBUSINESS: o9-9v - TVPEOFBUSINESS: 0 2DISTflIBIR09 4P CESSOR Box if INDIAN EPA 10 ft NOI7ANN's ❑ I GAS STATION ❑3 FARM ❑ OTHEfl TRUSTVLANOS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE cc X33/ 'f 201, 3 3szIS NIGHTS: NAME(LAST FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,F ST) PHONE p WITH AREA CODE l ( re k II l( lr 11. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME s CARE OF ADDRESS INFORMATION MAILING or STREET DRESS ox to intlicate 0 PARTNERSHIP ❑ STATEAGENCY 0 ' CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY r INDIVIDUAL 0 COUNTY-AGENCY CITU NAME O STATE ZIP COS�3�3 PHONE N,16.?WITH 2 3 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME 1 / Qy� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS Box to in0 tlicate ❑ PARTNERSHIP ElSTATE-AGENCY Q CORPORATION LOCAL-AGENCY 0 FEDERAL-AGENCY l 1 O INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STAT ZIP SCOPHONE N,WITH AREA CODE TDG -r O IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR SOTH 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 M AGENCY N FACILITY IDN N of TANKS at SITE 10101111 UO CURRENT LOCAL ADEN Y FACILITY ID N�� APPROVED BY NAME PHONE N WITH AREA CODE 5 PERMIT NUMBER PERMIT AIRDA PERMIT EXPIRATION DATE LOCATION CODE DE CENSUSCT If ISTRICT CODE BUSINESS PLAN FILEDDATE FILED .] U YES NO E] CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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. ^I FORMA(3-2-88) •J` w \ DATA PROCESSING COPY