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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD y` '^OT 'f FORMW: : UNDERGROUND STORAGE TANK PROGRAM u �a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑p INTERIM PERMIT 4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE •O I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) IWI� FACILITY/SITE NAME 0 CARE OF ADDRESS INFORMATION WAN ADDRESS �D 51 EAREST CROSS STREET NiApb 0 PARTNERSHIP 0 STATE AGENLY C0.9PGRAigN ❑ LGCA4AGENLY ❑ FEGEPALAGENLY ❑ INGNIWN ❑ WUNIYAGENCY CITY NAME STATE ZIP COD SITE PHONE#,WITH AREA CODE cA 337 G ti? ;gXd TYPE OF BUSINESS: p DISTRIBUTOR 4 ESSOfl ✓Box ii INDIA EPA ID a ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUSRESET LANDS ATION or ❑ A THIS siTE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) t PHONE# RE WITH AREA CODE S6,08 `� —835-d`b' le 203S-8frd NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FI T) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME /' CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicale ❑ PARTNERSHIP ❑ STATE-AGENCY 0 // ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY JJJ 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME �`�� STATE O ZIP COQE a� PHONE p,WITH AREA CODE 6 Ill. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S4►'Kf R MAILING or STREET ADDRESS ✓Box to iFdicale 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. II. ❑ 111. 771 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 a AGENCY# FACILITY ID At #of TANKS at SITE m16iol ff Y CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA CODE /�/STZ r PERMIT NUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE LOCAT� ODE CENSUSTRACT#SUPERVISOR-DISTRI CODE BUSINESS PLAN FILED DATE FILED 2 YES [] NO ❑ ,_/ Q CHECK# PERMIT AMOUNT SURCHARGE AMOU T FEE CODE RECEIPT# BY; wS 1� THIS FORM MUST BE ACCOMPANIED BY AT LEA T It)OR MORE TANK PERMIT FORM `B'APPLICATION(S), I I LESS THIS IS A CHANGE OF SITE INFORMATION ONL . \ FORMA(3-2-88), �j DATA PROCESSING COPY