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STATE OF CALIFORNIA► WATER RESOURCES CONTROL BOARD .•t FORM LAI: UNDERGROUND STORAGE TANK PROGRAM SITE O FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION % COMPLETE THIS FORM FOR EACH F LITY/SITEF MARK ONLY ❑ I NEW PERMIT ❑7 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑d AMENDED PERMIT ❑fi TEMPORARY SITE CLOSURE Qa O 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) co CAJ FACILITY/SITE NAME CARE OF ADDRESS INFORMATION W -5117CII OW rD ADDRESS C / NEAREST CROSS STREET ✓NP Rma4 0 PMTNEIBHP 0 STATE AGENCY OCWY COWOINION O LAAGEENCYElRDERAL AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE S/-0c,F/v"-� CA S (do�) 9v8 5°si� TYPE BUSINESS: ❑y DISTRIBUTOR ❑1 PROCESSOR J Box it INDIAN EPA 10 N RESERVATION or N of TANK'N I GAS 5fA1gN ❑3 fAfW ❑S OTHER TRUST LANDS ❑ G1 K AT THIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(EAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE ✓, %e,�u G.5`i 2 - n -V3/S / NIGHTS NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: AME(LAST.FIRST) PHONE N WITH AREA CODE . f -'/sd - v/& - e' er II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS J to inaicala 0 PARTNERSHIP ❑ STATE-AGENCY c./ O, CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL AGENCY /_-3 G2,11a".2c /!i/ 0 INDIVIDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ :lo intfica1. 0 PARTNERSHIP 0 STATE-AGENCY CORPORATION 0 LOCAL-AGENCY 0 FEDERAL AGENCY /t0 INDIVIDUAL 0 COUNTY AGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE r car 5d 2_, 611,5_ IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(T)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. ❑ 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 N JURISDICTION N AGENCY N FACILITY ID N N of TANKS of SITE = = 1 O 1 Z / 1 0 y CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE Y WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ll 3 6 YES NO [] /a/' I CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: C THIS FORM MUST BE ACCOMPANIED BY AT LEAST 111 NR MORE TANK PERMIT FORM 'B'APPLICATION(S), ' --SS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-811) �� DATA PROCESSING COPY