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I� LEp�Of �N\ STATE OF CALIFORNIA WATER RESOURCES CONT BOARD `A': o-3 " FORM ` UNDERGROUND STORAGE TANK PROGRAM `o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 1,N COMPLETE THIS FORM FOR EAC A LITY/SITE MARK ONLY EW PERMIT F-13 RENEWAL PERMIT JIM 5&ANGE OF INFORMATION ❑ 7 Y CL N ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) 4�. FACILITY/SITE NAME CARE OF ADDRESS INFORMATION s TATE AGENCY ADDRESS NERR�$T OSSS Itj 64W I oINGRATION 0UAL ❑ COUNTY NTY AG CY ❑HIP [I FEDERAL-AGENCY 13 zo 5 ZIP CODE SITE PHONE p.WITH AREA CODE CITY NAME STATE cS_&�✓ CA 9Si4 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR n 4 P50CESSOR -/Box if INDIAN EPA ID p p of TANK'S L��/OTHER RESERVATION or ❑ AT THIS SITE ❑ 1 GAS STATION [-] 3 FARM TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) MyE DAYS: NA (IAST FIIR T) PHONE p WITH AR A CODE DAYS. N �IAp/E`LASS 'T.FIRST) PHONE 4 WITH AREA CODE �� D NIGHTS: NAME(FAST C`FIR`STT)__A PHONE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ` CARE OF ADDRESS INFORMATION e C/�/ DDR S ✓Box to indicate ❑ PARTNERSHIP El STATE-AGENCY MAILING or STREET A G/J� CORPORATION ❑ LOCAL-AGENCY [IFEDERAL-AGENCY `/LY (��SJ"-✓U ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE /ZIP CODE PHONE p,WITH AREA CODE S lcN III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAMEr CARE OF ADDRESS INFORMATION DON Di5-r6& (ATj66,_ MAILING or STREET ADDRES ✓Bex to indicate EI PARTNERSHIP [ISTATE-AGENCY o ❑ CORPORATION ClLOCAL-AGENCY ElFEDERAL-AGENCYI Y3oX 2 6 ElINDIVIDUAL ❑ COUNTY AGENCY CITY NAME BTATB ZIP CODE ' / PHO WITH AREA CODE �� Tka IV. LEGAL NOTIFICATION AND BILLING ADDRESS (!�7^ CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ 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 R AGENCY# FACILITY ID M #of TANKS at SITE UooI CURRENT LOCAL AGENCY FACILITY ID a APPROVED :NAME PHONE p WITH AREA CODE bNSDNPERMIT NUMBER PERMIT APPROVAL DATE _/ MIT EXPIRA ON DATE LOCATION CODE CENSUS TRACT p SUPERVISOR- (STRICT CODE INESS PLAN FILED DATE FILEDYES NO ❑CHECKp PERMIT AMOUNT SURCHARGE AMOUNT FEE RECEIPT p BY: if LL 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 ONLY. /FORMA(3-2-R8) 1 RE `\ DATA PROCESSING COPY