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r <br /> STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD <br /> FORMW: <br /> SITE UNDERGROUND STORAGE TANK PROGRAM FACILITY/SITE, V� �o <br /> Y/SITE, INFORMATION and/or PERMIT APPLICATION <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE _> 1 C5 <br /> rMARK,CNLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OFINFORMATIONONE TEM ❑ 2INTERIM PERMIT � 7 PERMANENTLY CLOSED SITE N <br /> 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 90 Qy <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) �J pip <br /> FACILITY/SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> oti c%lr� <br /> ADDRESS r (� ,ry Er <br /> NEAREST CROSSt STREET ✓Bor loiMicale C3PARMER s ElFAT&AGEN E57;1;UTION ❑ LOA-AGENCY ❑ FEDERAL- <br /> AGENCY <br /> CITY NAME ❑ INDNDwL ❑ GDUNIY AGENDY <br /> STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> oe fog �#Z06 <br /> TYPE OF BUSINESS: ❑2 CA #,DISTRIBUTOR ❑ q PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ I GAS STATION ❑3 FARM ❑ 5 OTHER RESERVATION or #of TANK'# <br /> TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION a ADDRESS — (MUST BE COMPLETED) <br /> NAME <br /> DARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 13COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP Cl STATEAGENCY❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> ❑ INDIVIDUAL ElCOUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ II. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) PATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID It If of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE - <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> ?l, F'Q *?,Z 5— YES NO Z [/( <br /> CHECK# PERMIT AMOU SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPD ATieAST,"`nR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLFOR THIS IS A CHANGE OF SITE INFORMATION ONLY. I <br /> FORM A(3-2-88) Q <br /> n I -aL} \ �' '�' DATA PROCESSING COPY 19.0 <br /> U <br />