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STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD FORMA": SITE UNDERGROUND STORAGE TANK PROGRAM um ^" FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACb&FACILITY/SITE <Fo;H,a HG MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM 5 CHANGE OF INFORMATION ❑2 INTERIM PERMIT ❑N AMENDED PERMIT TLY CLOSED SITE F_A 6 TEMPORARY SITE CLOSURE 5O -4 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME 00 CARE OF AD---wnm^l lull N at�el S_ ut�� ADDRESS /YA r. NEAgEST�ROSS STREET ✓ roiMirAe NJA- 0 PANRIEW R 0 STATEAGENCY CITY NAME G N Q,N CDROMPGN 11LOCAL-AGENCY ❑ FEDERAL-AGENCY NOMOUAL 0 COIINIY AGENCY STATE ZIP CODE SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 ESSOR ✓Box if INDIAN EPA ID pA A o _ ❑ 1 GAS STATION ❑3 FARM 5 OTHER RSETRUST LANDS or ❑ N M TANK'N EMERGENCY CONTACT PERSON(PRIMARY) AT THIS SITE IA NAME(LAST,FIRST) CONTACT PERSON(SECONDARY) DAY : NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIgST) QIII l _to 3,6PHONEN WITH AREA CODE NIGHTS: AME(LAST,FIRST) 1 NE N WITH AREAO CODE NIGHTS: AyE F1gST,FIRST) S !Y A PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &fAJ'DDRESS — (MUST BE COMPLETED) NAM + �� CARE OF ADDRESS INFOgMATION MAILING or STREET ADDRESS ` 1 ✓Box to indicate 0 PARTNERSHIP ❑ STATE-AGENCY motA C1 I� ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY CITY NAME ❑ INDIVIDUAL 0 COUNTY AG S-�o�k4o STATE ZIP CODE 1 PHONE N,WITH AREA CODE U7T- 175 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED)a o N C' ! -rc CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PpgTNERSHIP ❑ CORPORATION ❑ LOCAL-AGENCY CSTATE-AGENCY CITY NAME ❑ INDIVIDUAL ❑ COUNN- CFEDERAL-AGENCY AGENCY 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. 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION S AGENCY N Ea FACILITY ID N V N o/TANKS at SITE 1 V CURRENT LOCAL AGENCY FACILITY 10 N ELT O APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBE PERMIT ApppOyAl DATE PERMIT E%PIRAT ON DATE LOCATION CODE /CENSUS TRACT N SUPERVISOR-DISTRICT'CODE BUSINESS PLAN FILED U 23, /CD LED YES [] NO [:] /SIS CHECKN pEgMIT AMOUNT SURCH RGE AMOUNT V, FEE CODE RECEIPTN 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. FORMA(3-2-88) DATA PROCESSING COPY P