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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ;:• °"`* FORMW: ( `; UNDERGROUND STORAGE TANK PROGRAM s � 1 IW) SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE �1�++ MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM NTLY CLOSED SITE �I ONE ITEM ❑2 INTERIM PERMIT ❑ / AMENDED PERMIT ❑6 TEMPORARY SITE CLOSUREy Q .0 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) w FACILITY/SITE NAME CARE OF ADDRESS INFORMATION C C c ADDRESS NEAREST CROSS STREET �✓Aw�` 11PMTNERSNP ❑ SiAIE AGENCY m /q/ C LT-COIY TION 11LOCALAGENCY E) RLL FEDEAGENCY ��C/H /Y, .J1 _ ❑ LNNIVIGAL ❑ COINiYd END CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE CA ac-- vbs 'was J TYPE OF BUSINESS: ❑ 2 OISTWBUTOR ❑/ SSOR ✓Box it INDIAN EPA ID N ❑ I GAS STATION ❑3 FAROTION 5 OTMFA TpUSTYLANDS ul ❑ AT THIS SITE L.y EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(L.AST,FIRST) PHONE Y WITH AREA CODE DAYS: NAME(AST.FIRST) PHONE N WITH AREA CODE Sa ..-._� NIGHTS: NAME(LIST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE cl . -'C- II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME I CARE OF ADDRESS INFORMATION v MAILING w STREET ADDRESS ✓Box ind,cale ❑ PARTNERSHIP ❑ STATE-AGENCY 3 ❑ PO TION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE C 19 951 5 Zvry Y�-s III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sa P c< S LL7 MAILING w STREET ADDRESSn✓Do�oindicate ❑ PARTNERSHIP ❑ STATE-AGENCY u�cvRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY 444111"""INDIVIDUAL ❑ CDUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOY INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. 11. tll. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYLI JURISDICTIONN# AGENCY N FACILITY ID It R of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAPE PHONE Y WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE LOCATION COOK CENSUS TRACTS SUPERVISOWDISTRICT CODE BUSINESS PLAN FILED DATE FILED -3 YES El NO � 12- _611.1 2- CNECK E PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N By; THIS FORM MUST BE ACCOMPANIED BY AT LEAST(FORE TANK PERMIT FORM 'B'APPLICATION(S), UNL�HIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-BB) L -V' ,"I V DATA PROCESSING COPY