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y�OF JH\ <br /> STATE OF CALIFORNI WATER RESOURCES CONTROL BOARD <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM fm. <br /> o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE Cq 11FORNxP <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 4jr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE � , L" <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) V <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATI N <br /> GSDS C^� cameo <br /> ADDRESS NEAREST CROSS STREET VPIORAT <br /> ndicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> DUALION ❑ COUNTY-AGENCY <br /> El LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA �:2!2Z:8t5y-2-a6 <br /> TYPE OF BUSINESS: ❑2&STRIBUTOR ❑ 4 PROCESS7RE <br /> Box if INDIAN EPA ID # <br /> ❑ ❑ ❑ STTVL <br /> RESERVATION <br /> DS or ❑ #of TANK's <br /> 1 GAS STATION 3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITHAREACODE DAYS: NAME(LAST,FIRST)_ PHONE#WITH AREA CODE <br /> Ci <br /> NIGHTS: NAMEW.ST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME LAST,FIRST) PHONE#WITH AREA CODE <br /> C- es &Agm�- 010-r-sm 2z�1 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRE S ✓ x to indicate El PARTNERSHIP ElSTATE-AGENCY <br /> //"� ORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> �A$L' � <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> 23 51-31 <br /> CURRENT LOCAL AGENCY FACILITY 1 APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRAST# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> 2_3" <br /> YES ❑ NO ❑ , �— ` <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT T�ODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASTSR MORE TANK PERMIT FORM 'B'APPLICATION(S), US THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />' FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />