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STATE OF CALIFORNIA WATER RESOURCES CONTR"OARD FORM RA': UNDERGROUND STORAGE TANK PROGRAM SITE \70I FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PE CLOSED SITE ONE ITEM ❑ 3 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FA /SIMEw CARE Cf IV A ADDRESS INFORMATION CARE QFDRESS INFORMATION AD E 7 1 Z" Al1 / / Vx/ %/ Box to indicate ❑ PARTNERSHIP 11ERA CORPORATION ❑ LOCAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY EST CROSS STREET ✓Bm WirAGle ❑ PARTNERSHIP ❑ IST AT ❑ OOR'ORATION ❑ LOCAL AGENCY FEDDUL ENp Cl INDIVIDUAL ❑ CUUNttAGEN CITY E_ ,�.-/_— 7(/NL//p'/Tl`i—I ZIP CODE c2 _ STATE CA ZIP CO ITE PHO Z69 p WITH AREA CODE Z WTYPE BUSINESS. ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ,GAS STATION ❑ 3 FARM ❑ 5 OTHER ✓Box it INDIAN TRUSESETYLA IDS ATION U ❑ EPA ID��a VI(A If of TANK's AT THIS SITE J EMERGENCY CONTACT PERSON (PRIMARY) BUSINESS PLAN FILED p YES [:]NO EJ�/ EMERGENCY CONTACT PERSON (SECONDARY) DAY NAME (IAST, FIRST)PHONE M WITH AREA CODE K o /_ z8/ DAYS: NAME (LAST, FIRST) PHO M WITH AREA CODE 1 S NIGHTS. NAME (LAST, FIR I - Ag PHO E N WITH AREA CODE S4 NIGHTS: NAME QRST, FIRST) Pr S/64 HO E N WITH AREA CODE a 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME - Ll�IW IAI-V CARE Cf IV A ADDRESS INFORMATION MAILING or STREET ADDRESS MAILING or STREET ADDRESS QQ r4� %/ Box to indicate ❑ PARTNERSHIP 11ERA CORPORATION ❑ LOCAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY ❑ STATE -AGENCY FEDNCY -AGE CITY NA STATE CA ZIP CODE c2 _ PHONE #. ITH AREA CODE I3/ -o&5 i Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME 514 ff- CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓ Bax to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY CUA NT LOCAL AGE �ACILITY IDM ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY APVROVED BY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME $TATE ZIP CODE PHONE il, 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: L z 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 R 35 JURISDICTION M AGENCY R FACILITY IDR M of TANKS at SITE 196 1 ! �3 op 103 CUA NT LOCAL AGE �ACILITY IDM APVROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATlj CODE CENSUSTRACT.j- / SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED p YES [:]NO EJ�/ DAT FILED 17-z CHECK M PERMIT AMOUNT SURCHARGE AMOUNT, FEE CODE RECEIPTR BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM `S' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA (3-2-88) - i'(/ )%.f, DATA PROCESSING COPY ti�