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STATE OF CALIFORN& WATER RESOURCES CONTRIPBOARD F FORM IA': UNDERGROUND STORAGE TANK PROGRAM = " �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION / Z COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Jaz I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACIE 7SITENAME 1 CARE OF ADDRESS INFORMATION ADDRESS / NEAREST GROSSSTREET /� ✓Sacred# ❑ PARTNEFEW ❑ STATE AGENCY �G l nV r b `lam ❑ IIND g1AL� ❑ GYJNTr AGENCY Cl U)Ck-AGENCY ❑ FEOEPAbAGENCY CITY NAME STATE ZIP CODE SITE PHONE N. L O C6. CA WITH AREA C .310 _1 �7 TYPE OF BUSINESS'. ❑ 2 DI IBLROR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID p #of TANK'1 ❑ 1 GAS STATION 3FARM 5OTHER RESERVATION or AT THIS SITE O ❑ TRUST LANDS ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE it WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE M WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION err d- DOAV PL. Co i u C,_ MAILING or EET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY L� , —)�j� ` El El 11LOCAL-AGENCY ClFEDERAL-AGENCY/� OS ' v ' S DC �A ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE Lccu C /4 1 7 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE it,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: 1. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION M AGENCY R FACILITY IDR K of TANKS at SITE " iql IP- 1-71 a � 60 0 CURRENT LOCAL.AGENCY FACILITY ICI NI WITH BY NAME PHONE 4 WN AREA CODE PERMIT NUMBER I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC N ODE CENSUS TRACT M SUPERV1 R-018TRICT CODE BUSINESS PLAN FILED DA E FILED YES NO ��— CHEC k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMR FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. ORM A(3-2-8e)