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STATE OF CALIFORNIP WARESOURCES CONTROw'gmh'OARD T P yE/+ FORM ' '® UNDERGROUND STORAGE TANK PROGRAM _ �'m a 0 SITE FACILITY/SITE, / APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITEEMARIK LY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ®7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ro I. FACILITY/SITE INFORMATION — ( ) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ to indicate ❑ PARTNERSHW ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 5044uld 5T �"r ❑ INDMOUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE It,WITH AREA CODE 5-r-4oz�k—rOAI CA l(zoA)cIq3_ q,065 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ®4 PROCESSOR ✓Box if INDIAN EPA ID# V RESERVATION or #of TANICs 1 GAS STATION ®3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCYC TACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#�pWITH AREACODEDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE / y NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION —(MUST BE COMPLETED) NAME FCAREOF ADDRESS INFORMATION MAILING or STREET ADDRESS Box to indicate ElPARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY t D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME ZIP CODE PHONE#,,WITH AREA CODE ( tS) ®05'6 III. TANK OWNER INFORMATION —( ) NAME ®®® CAREppOFADDRESSINFORMATION r L MAILING o STREET ADDRESS _/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY V ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING CHECK ONE(1)BOX INDICATING WHICH ABOVE ASHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. 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 Y CO UNTY* JURISDICTION AGE CY FACILITY ID# #of TANKS at SITE0 10 f 16 NCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUS ACT# SUPERVISOR-DIS ICT CO BUSIE N FILED DATE FILED �yYES r 7i 17 1-111/PERMIT AMOUNT SURCHARGE AMOUNT E CO RECEIPT# BY: THIS FORMUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERmrrAPPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88)