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STATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD FORMW:: UNDERGROUND STORAGE TANK PROGRAM �o SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH CILITY/SITE MARK ONLY F71 NEW PERMIT F__] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ LY CLOSED SITE Al ONE ITEM [:] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 8'a 4m N I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION ADDRESS a NEAREST CROSS STREET ✓Banta indale 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 11OCA4FEDERAL-AGENCY LOCAL-AGENCY ❑ FEDERAL-AGEN J (�L / ✓ �`��" ClINDMDUINDMWAL 11 COUNTY-AGENCY CITY NAME STATCA ZIP OlD�� SITE PHONITH ODE TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑ 4PROCESSOR ✓Boxif INDIAN EPA ID ITof TANK's ❑ 1 GAS STATION ❑ 3 FARM ❑ RESERVATION or AT THIS SITE 5 OTHER TRUSTLANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE �i�v4 -�6if-3 S7 NIGHTS: NAME(I FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(UST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME _ Gv vl on/ CARE OF ADDRESS INFORMATION MAILING or STREETJ�DDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY �/ ^T /) �. /' ❑ CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAMESTATE ZIP CODE PHONE#,WITH AREA CODE s � SJAO III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME Is , Ty /7o I Nkevi f I CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ` I/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY C 0 INDIVIDUAL 0 COUNTY-AGENCY CIN NAME � `� STATE I ZIPCODE��/ PHONE p,WITH AREA Coo ��rEF3� IV. LEGAL NOTIFICATION AND BILLING ADDRESS (^//r�T� SS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. Lien 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 m = = LQk " 10 1 DI CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE -u s PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION�FODE CENSUS TRACT# SUPERVISOR-DIST ICT CODE BUSINESS PLAN FILED DATE FILE G �l, YL Q 7j YES NO l�Z? CHECK# 1 PERMITAMOUNTSURCHARGE AM UNT FEE CODE RECEIPTM Y: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)0 MORE TANK PERMIT FOR M 'B'APPLICATION(S), UNLESHIS IS A CHANGE OF SITE INFORMATION ONLY. L DATA PROCESSING COPY f�