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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD Wr FORMW: : V UNDERGROUND STORAGE TANK-PROGRAM �a i S7MARK FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) I FACILITYISITE NAME CARE OF ADDRESS INFORMATION k ADDRESS - NEAREST CROSS STREET ✓gp toldcge ❑ PARERSHIP ❑ SATEAGENC! ry 11 -7 14 ❑ OORATIO ❑ lY El FE3EPAL AGEHCr 1(-/, a, L J4;,, �� ,LGIqUp— ❑ WMDAL ❑ CDUNTY,AGENCr r- CC CITY NAME STATE ZIP CODE SITE PHDN #,WITH AREA CODE .,CAI IF5Ad C20 , Y66-0316 TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR '/Box it INDIAN EPA ID # Iw� n1 ❑ 1 GAS STATION ❑ 3 FARM �THER TRUST LANDS Ga ❑ l V �r v � +ti of T THIS AT THiB SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME{LAST,FIRST) PHONE#WITH AREA CODE Lo_r r W r a (Aqf 966-6 37 NIGHTS: NAME( S ,FIRST) PFTONE It WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE e C�. a 7-0(o 6 � II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME rr CARE OF ADDRESS INFORMATION , MAILING or STREET ADDRESSy - ✓Box to indicate 13 PARTNERSHIP © STATE-AGENCY r e f ❑ CORPORATION ClLOCAL-AGENCYCl FEDERAL-AGENCY A..i .❑ INDIVIDUAL ❑ COUNTY-AGENCY J1 j CITY NAME STAT ZIP COD PHONE#.WITH AREA CODE l L f< cti K Ili. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME T ��11 CARE OF ADDRESS INFORMATION i �• r V MAPING or STRE ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY O? L ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEOERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY j CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 75 IV. LEGAL NOTIFICATION AN6 BILLING ADDRESS .I CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ II. ❑ ill. ] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. 1 APPLICANTS NAME;(PRINTED&SIGNATURE) DATE i i LOCAL AGENCY USE ONLY i COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE all I 1 1 . 71 L-) 4 1 / I / . 3 000 .l I CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE I . 4 114 In PERMIT NUMBER .PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE € i I i LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE - BUSINESS PLAN FILED DATE ILED p YES NO d +7 CHECK# PERmrt AMOUNT SURCHARGE AMOUNT - FEE GORE RECEIPT# Y: I , I . THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. RM A(3-2-88) I` DATA PROCESSING COPY 0._,