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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD zE o* M1f W. FORMA': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS ! COMPLETE THIS FORM FOR EACH FACT ITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT El4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE " ^1 CD O� CD I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION R,/0, Bar7i ADDRESS NEAREST CROSS STREET Box to inddcale ❑ PARTNERSHIP ❑ STATE-AGENCY 3 ❑ C BION ❑ LOCAL AGENCY ❑ FEDERAL.AGENCY / a NI FYI GIVIOIIAL ❑ COUNTY AGENCY CITY NAME _ STATE ZIP CODE SITE PHONE#,WITH AREA CODE /Q/ n CA 75366 a -g/o -o23-O/ TYPE OF BUSINESS'. ❑ 2 DIST OR ❑4 PROCESSOR ✓Box if INDIAN EPA ID ft VATION or `/ ❑ I GAS STATION FARM ❑ 5 OTHER RESETRUST LANDS ❑ U/c.- AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LOST,FIRST) PHONE#WITH AREA CODE n2 — SD 5- ryN NIGHTS: NAME(LAST,FIRST) u .—�PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE Jew ava -sqy-aaA 5,a vY.Q II. PROPERTY OWNER INFORmAriON &ADDRESS — (MUST BE COMPLETED) NAME //// CARE OF ADDRESS INFORMATION /i / MAILING or STREET ADDRESS ✓Cox. """ate LlPARTNERSHIP ❑ STATEAGENCY 5 JdOHPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE �s lon CA 953�c� fIlo9- ash/ 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 9ve 0,2— MAILING Or STREET ADDRESS I/SO t$ind No ❑ PARTNERSHIP ❑ STATE-AGENCY O f.BRPORATION ❑ LOCAL AGENCY ❑ FEDERALAGENCY NDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N,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. 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# JURISDICTION# AGENCY# #of TANKS at SITE 3 gq 13 1 t 15 0 0 0 3 CURRE L A CILITY ID# APPROVED BY NAME PHONE At WITH AREA CODE �3A � PERMIT NUMB AL DAT PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT## SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED 05- 1R 3av2 3,-{o YES ❑ NO ❑ 3 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) ✓✓✓/// J1 .- '5 -2�-'�'� • DATA PROCESSING COPY