SITE INFORMATION AND CORRESPONDENCE

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I STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD :: FORM SAI. UNDERGROUND STORAGETANK PROGRAM SITE FACILITY/SITE, ,r INFORMATION and/or PERMIT APPLICATION '° COMPLETE THIS FORM FOR EACH FACILITY/SITE ti � {� C` IIFORN��- MARK ONLY F1,-,,�� ❑ I NEW PERMIT E] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION I ❑ 7 PERMANENTL LC SED SITE .tGj 1 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE • I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) w FACILITY/SITE NAME CARE OF AODRESS INFORMATION . . ��/ 1 s ; ADDRESS NEAREST CROSS STREET ✓Bpr17'rgic& ❑ PAATNERW ❑ STATE-AGEK-( L❑9'�DWI)FIATION 11 �nEr ACKY ❑ FkwRAL.AGDaCy CITY NAME STATE ZIP CODE SITE PHONF 0,WITH AREA CODE CA TYPE OF BUSINESS: 2 DISTRIWTOR 4 PROCESSOR ✓BOM if INDIAN EPA ID ii f ❑ I GAS STATION ❑3 FARM ❑5 OTHER RESERVATION or I M of TANK': ; TRUST LANDS ❑ /'�[I000. 1.5731k7 ,' AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS; NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: 1 NAME(LAST,.FIRST) ' ! PHONE K WITH AREA CODE i r �J G - y' -/oT 3/ �i,'I- 1 , r '� NIGHTS: NAME(LAST,FIRST) PHONE N 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 MAILING or STREET ADDRESS ✓ o Intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE d /mss Cr49�'vY�. i III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) I } NAME CARE OF ADDRESS INFORMATION 7 cI - SGz> e a S :i MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY M ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ IN[)141OLIAL ❑ COUNTY-AGENCY CITY NAME STATE ff ZIP CODE PHONE N.WITH AREA CODE E, IV. LEGAL NOTIFICATION AND BILLING ADDRESS ! =CHECKONE V BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ,❑ 11. 111.❑ s THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED a SIGNATURE) y DATE'I I LOCAL AGENCY USE ONLY I COUNTY-M JURISDICTION E AGENCY M FACILITY ID N I M of TANKS at SITE yL3 I a .3 Z[o t-/ , E� , 0 c CURRENT LOCAL AGENCY FACILITY ID/ APPROVED 8Y NAME PHONE N WITH AREA CODE $ PERMIT NUMBER- PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ' { LOCATION CODE CENSUS TRACT/ SUPERVISOR-DISTRICT CODE AUSINESS PLAN FILED DATE FILED C/ 3 t�O 3 � s YES ❑ NO '1 ❑ Iol�r�/ CHECKS PEAMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT I E3Y: li II - THIS FORM MUST BE ACCOMPANIED BY AT LEAS"'-)R MORE TANK PERMIT FOR M 'B'APPLICATION(S), IS FORM A(3-2-88) S THIS 15 A CHANGE OF SITE INFORMATION ONLY. ��, DATA PROCESSING COPY `y "