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STATE OF CALIFORNIA WATER RESOURCES CONTROMIOARD lull mo' FORMA AI: UNDERGROUND STORAGE TANK PROGRAM SITE F`4CILITY/SITE, INFORMATION and/or PERMIT APPLICATI C� COMPLETE THIS FORM FOR EACH FACILI /SITE MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 TLY OS SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE r/ I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME /� CARE OF ADDRESS INFORMATION 64 ADDRESS //�� II A C/'(J,"V NEAREST CROSS STREET ✓Bw N Mcm0 ❑ ERSH PARTNIP [1 STATE-AGENCY /�/L d W D D INNOONIWALIGN D Lcoufm acy ❑ RDERN.AGENCf CITY NAME STATE ZIPCODE SITE PHONE N,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2DISTRIBUTOR ❑ 4 PROCESSOR -/Box 6INDIAN EPA ID N Fof TANKS ❑ 1 GAS STATION ❑ 3 FAPM ❑ 5 OTHER RESETRUSTVLANDS ATION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME 5!4 �^O _ / n � ��w � CARE OF ADDRESS INFORMATION MAILING or STREET DRE✓SSI, ,V J/ ,V�! ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY �( D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY t O , d /� D INDIVIDUAL D COUNTY-AGENCY CITY NAME ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE/COMPLETED) J` NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS -/Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION V AGENCY N FACILITY ID M N of TANKS at SITE 16 1 � aI I I I I i CURRENT LOCAL AGENCY FACILnylllON 5' APPROVED Y NAME PHONE N WITH AREA CODE PEBMR MBER PE MIT APPROVAL DATE PERMIT EXPIRATION DATE L TON DE C[ SUE-TIIAC ^ PERVISOR-DISTRICT CO BUSINESS P D DATE FILED UU C/ YES NO ❑ X CKN RMIT AMOUNT SURCHARGE AMOUNT FE CODE RECEIPT N BY:�� \�� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TA rt ORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY