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STATE OF CALIFORNIA WATER RESOURCES CONTROL-BOARD 9 FORMA': UNDERGROUND STORAGE TANK PROGRAM m" SITE /- FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION v COMPLETE THIS FORM FOR EACH Fff LITY/SITE FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PE ENTLY CLOSED SITE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMITLj 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION i Le F duce ADDRESS NEAREST CROSS STREET ✓Butondimle 0 PAUNERSHIP 0 STATE AGENCY �J Q 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL V 1 V, ❑ INOIADUAL 0 COUNTYAGBICY CITY NAME STATE DECODE SITE PHONE A,WITHAREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 OCESBOR 013ox if INDIAN EPA ID a RESERVATION or Is of TANK'e �I ❑ 1 GAS STATION ❑ 3 FARM LV 5 OTHER TRUST LANDS ❑ AT THIS SITE v EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE —535_-51Z3 s cd-4 SSI Z NIGHTS: NA ( .ST,FIRST) PHONE N WITH AREA C DE NIGHTS: NA (LAST,FAST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 5'QfW�e of MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY Cm NAME STATE ZIP CODE PHONE#.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESSR ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY j7q// 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY s _ 0 INDIVIDUAL 0 COUNTY-AGENCY CITU NAME STATE I•IT ZIP CODEPHONE k,WITH REA CSO IV. LEGAL NOTIFICATION AN ILLING ADDRESS A'+JL{ 9 S CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE = = = 1610 1 i � 171 X01 10 CURRENT LOCAL AGENCY FACIQU Wt APPROVED BY NAME PHONE a WITH AREA CODE / ' Git PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DIST CT CODE BUSINESS PLAN FILED DATE FILED qo� -- y?� gCJ y YES NO CHECK#' PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT Al BY: .. THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)OR MORE TANK PERMIT FORM IB'APPLICATION(S), UNI ESS THIS IS A CHANGE OF SITE INFORMATIONjtY-, \ FORM A(3-2-88) W \� -Pi V DATA PROCESSING COPY I /