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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD A FORM i UNDERGROUND STORAGE TANK PROGRAM SITE F FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ao 0 COMPLETE THIS FORM FOR EACH FACILITY/SITE FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL LOSEDSITE F+ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE BO I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) C) 00 FACILI /SITENAME CAREOF DDRESS INFORMATION ADDRE NEAREST CROSS STREET ✓Bm W Ytlmb 0 PAATNERSNP 0 STATE AGOV W 0 WIIPOF TON ❑ LOGI-AGENp DEPIdENLY G 0 "C",AL 0 COUN7VAGENCI CITY NAME STATE ZIP CAPE SITE PH NE#.WITH AREA CODE LdD I CA �iSZyb Zo 339 146 TYPE OF BUSINESS: 2 DISTRIBUTOR ❑ 44 PROCESSOR ✓Box it INDIAN EPA ID F ❑ ❑ R TRUSRESETYLANDS ATIONof ❑ a AT HIf of IS SITE B� I GAS STATION 3 FARM 5 OTHEfl EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) F`3 N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHON p WITH AREA CODE S A S/A� A II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARED ADDRESS INFORMATION MAILING or STREET AD $B _ - ✓Box lQdgtlicate 0 PARTNERSHIP 0 STATE-AGENCY 8 8 !76S 0 CORQORATION 0LOCAL-AGENCY DERA iAGENCV 0 INDIVIDUAL 0 COUNTYAGLNCY Lt^�Iw CITY NAME11c STATE ZIP CODE /, , PHONE A,WITH AREA CODE Ga � S ,��n III. TANK OWN R INFORMATION &ADDRESS — (MUST BE COMPLE i NAME CARE OF ApR?TNflbRMATrON MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILL NG ADDRESS CHECK ONE(1)BOX INDICATINOWNN:N ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. Rr 111.❑ 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 M JURISDICTION 1t AGENCY M FACILITY ID If It of TANKS at SITE H0 C) 9- 3 l0 5 1110 ) CURRENT LOCA AGENCY FACILITY ID N APPROVED BY NAME PHONE 0 WITH AREA CODE / / PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE E CENBUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN❑FILED NO j TE FI D 23 F6 CrjJ( PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# BY: 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 ONL FORM A(3-2-&B) - — '4 DATA PROCESSING COPY )1X�