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STATE OF CALIFORMr WATER RESOURCES CONTROL-60ARD ^ l F FORMA': UNDERGROUND STORAGE TANK PROGRAM a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC AGILITY/SITE `^��•o `" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT Ev 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S3 I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FAGUTY/SITE N � CARE OF ADDRESS INFORMATI0 � Nb o ADDRESS rI NEAREST CROSS STREET ✓BMWYErsle 1:1PARiNBIBMP 13 STAMAGDO 23 13 NEAREST 1:1 LOCAL WOO 0 ROBALAGBlLY 13 NBPAOU/L 0 CGNIYAmC/ CITY NAMESTATE ZIP CODE SITE PHONE It,WITH AREA CODE vv CA OrJ'"' 2617 - 4� 35' TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 P ESSOR ✓Box H INDIAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM OTHER TR STT LANDS RESERVATIONdr ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS NAME(LAST,FIRST) PHONE N WITH AREA CODE d0luvS - - s 5 Avk 2679 -%v- NIGHTS NAM ST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE Sr-?i'k _ ?2-'7-579,573 II. PROPERTY OWNER INFORMATION & ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION .VG MAILING or STR ADDRESS - ✓Box to indicate 0 PARTNERSHIP - 0 STATE-AGENCY .231^J 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 3 ❑ INDIVIDUAL 0 COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE Al,WITH AREA CODE Sd� S Z - 6 -963s III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME " _� CARE OF ADDRESS INFORMATION mS MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ADM ADDRUS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL In 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 R JURISDICTION Y AGENCY E FACILITY IDN N of TANKS at SITE 3 = 6 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE C 3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENWB T rMr��,CT N BUPERYISOR-0ISTRICT CODE BUSINESS PLAN FILED DA ALE .Z-3 . 0 2�"� YES E] NO ❑ CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS 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)