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,-.... s7.,..- '. .:..r'w;:?T_•w.rw!nr�i, (y`°IRd �.:- I• _ $ -T STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMW:: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION G COMPLETE THIS FORM FOR EACH FACILITY/SITE ,c FsR MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 NTLY CLOSED SITE 17110 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I O C-0 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) D FACILITY/SITE NAME / CARE OF ADDRESS INFORMATION ADDRESS t r/�(J NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE AGENCY / ElElCORPORATION ❑ LOCAL-AGENCY FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME5-7,aL/� �� STATE ZIP CSE(,2 S SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS. F__] [—]2 DISTRIBUTOR 4 P CESSOR ✓Box if INDIAN EPA ID a /y RESERVATION or #of TANK's 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME( T,FIRST) PHONE it WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER FORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY wqo ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE A-N 7 t-p GFT ;s- III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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. X 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# AGENCY# FACILITY ID# #of TANKS at SITE [0 1 1 Ill I I I 1010 IFL 1 a � CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NA E PHONE#WITH AREA CODE L6 �� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE -kf� LOCATION CODE CENSUS 'l SUPERVISOR- ST�CODE BUSINESS PLAN FILED DATE FILED V YES [:] NO CHECK# PERMIT AMOUNT 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 IS A CHANGE OF SITE INFORMATION ONLY. \ FORMA(3-2-88) \v DATA PROCESSING COPY