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P ALIFORNI WATER RESOURCES CONTRAOARD STATE OFC �A FORMW: : UNDERGROUND STORAGE TANK PROGRAM SITE _/y FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMMlk LOSED SITE 1 i ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ $ TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) Imo.► FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ZW ,/L/ e ADDRESS N AREST CROSS STREETVV ✓Bar IairArcale Cl PARTNERSHIP ❑ STATE-AGENGY '. 1 ` uC ❑ RPOAATION 11LOCAL-AGENCYClFEDERAL-AGENCY W. f � INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME F r STATE ZIP CODESITE PH NE# WITH AREA CODE 6e-A CA S�3— eF39,7 yrs TYPE OF BUSINESS' ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # #of TANK's RESERVATION or e-T-G'AS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS zt,❑ 14, AT THIS SITE e)l EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE It WITH AREA CODE GAYS: NAME(LAST,FIRST) PHO E#WITH AREA CODE ---S_.Ze"gU&Z, AL,_M 4, z_U0q)3 6 1 NIGHTS- NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PH/SNE#WITH AREA CODE h .3{'/� g1A II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NpF CARE OF ADDRESS INFORMATION /V� r MAILING or ST ET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY j ' ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 39 v t LiJ { 1�- i ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMt STATE ZIP CO�; PHONE#,WITH AREA CODE f (/_1 2 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME GARS OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGFNCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. it. ❑ Ill. ❑ 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 JJ EQ ( `� 1 Ld L-) o � � CURRENT LOCAL AGENCY FACILITY ID III APPROVED BY NAII PHONE#WITH AREA CODE ov _T PERMIT NUMBER PERMIT APPROVAL DATE ERMIT E)LPIRATI N DATlk ICH CATION CODE CENSUS TRACT# SUPERVISOR- ISTRICT CODE BUSINESS PLAN FILED DATE FILED /� A I� YES ❑ NO � 6— �1Igr ECK# PERMIT AMO09 UNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM [B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-681 0 DATA PROCESSING COPY 0