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STATE OF CALIFORNIA WATER RESOURCES CONTRA OARD Ayr; rN . • 'eun.r� •., A FORMW: : UNDERGROUND STORAGE TANK PROGRAMW 0 SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION, �� L/ COMPLETE THIS FORM FOR EAC"ACILITY/SITE C9�I Fo RA,P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMLAUF.Wf LY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE f lq I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME(( i- \J 6 V1 I /v co ('t Q: F l� CARE OF ADDRESS INFORMATION SA -P Zft(jIA �N `i ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ADDRESS ZIP CODE PHONE H. WITH AREA CODE NEAREST CROSS STREET ✓ Boz to indicate ❑ P NEHSHIP 1:1 STATE -AGENCY /y► /V+► t / PHONE # WITH AREA CODE ED UV i'//W El COUNTY -AGENCY CITY NAME FIrZ�GC. STATE ZIP CODE %523 SITE PHONE # WITH A A CODE e— CA � TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID # # of TANK's ❑ 1 GAS STATION [:]3 FARM ❑ 5 OTHER TRUSTVATION LANDS or r-1LANDSTHIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) QAYS: NAMELAST, FIRST) PHONE # WITH A�'v DE � PHONE #WITH AREA DAYS: NAME (LAST, FIRST) 7&-4 7-4- 7I(_ �G LPIIH"ONE NIGHTS: NAME ((LLA`/STT, FIRST) PHONE # WITH AREA CODE NIG S: NAME ( T IRST) # WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME 3A,jv i- \J 6 V1 I /v co ('t Q: CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS sT ✓ Box to indicate ❑ PTNERSHIP ❑ STATE -AGENCY ElCORPORATION CAL -AGENCY ❑ FEDERAL -AGENCY El INDIVIDUAL COUNTY -AGENCY CITY NAMEs1foll ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY STATE q ZIP CODE PHONE H. WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME.. . I CARE OF ADDRESS INFORMATION 14 Q-3 FACILITY ID # MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY u U/ -� ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS / I CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. IV III. ❑ I 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 # FACILITY ID # # of TANKS at SITE [Ty u U/ -� 0 GF6_7 CURRENT LOCAL AGENCY FACILITY ID # I APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER ' PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION ODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED DATE FILED �+ :3 8-U � ZYES NO CHECK #- PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY: G 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. I FORMA (3-2-88) DATA PROCESSING COPY —4 F -i f—