Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ' <br /> FORM W: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> CCOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARKC NLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT a5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ N AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> fACI TY/SITECCNAME CARE OF ADDRLSS INI UHMATION <br /> ADDRESS NEAREST CROSS STREET ✓N Wb 0 PMTW W 0 SIATEAU0 <br /> D3 N • NT S� 0 D)WOMPLN 0 LO AGVA7( Cl IEOEWIkEENLY <br /> 0 iNDV 0 COUNTYAGENCY <br /> CITY NAME STATE ZIPCODE SITE PHONE N,WITH AREA CODE <br /> S7DG/c?oA( CA Z (Zo9 9 - BSob <br /> TYPE Of BUSINESS: ❑2 DISTRIBUTOR ❑ /PIKICFSSOfl Box II INDIAN EPA IU A LL <br /> RESERVATION OI .1 TANK's <br /> AT THIS SITE OL+ <br /> ❑ I GAS STATION ❑ 3 FARM 5 OTHEfl TRUST LANDS ❑ <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE E WITH AREA CODE DAYS. NAME(UST,FIRST) PHONE N WITH AREA CODE <br /> 'TE V fA64(i <br /> NIGHTS'. NAME(LAST,FIRST PHONE N WITH AREA CODE NIGHTS'. NAME(UST,FIRST) PHONE E WITH AREA CODE <br /> s{� <2vq) 323 -56a <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE Of ADDRESS INFORMATION <br /> MAILING STREET ADDRESS ✓Boa Io iNOlcalV 0 PARTNERSHIP - ❑ STATE-AGENCY <br /> �O• /Y III ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> V ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A.WITH AR CODE <br /> 5T C4- ZO ZD4I 4116- Ssoo <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMES CARE Of ADDRESS INIOHMATION <br /> krV <br /> MAILING a STREET ADD/R�ES�S� ✓Bov mlmllcaln 0 PARTNERSHIP 0 STATE-AGENCY <br /> 3 00 �O¢t F/0 pli l OF G� CORPOVV TION ❑ LOCAL AGENCYCl FEDERAL AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY AGENCY <br /> CITY NAME ,F STAZIP CODE PHONE N WITH AREA CODE <br /> S/P�C��/F3�AivAT� CC..�i 5F5'I a►� <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CNECK ONE(1)BOK INDICATING WHICH ABOVE ADORES$SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. E�K 111. ❑ <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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY40 JURISDICTION Y AGENCY F FACILITY 10 E E of TANKS at SITE " <br /> m = I o o o e) 10 167 <br /> CURRENT LOCAL AGENCY FACILIT/IDE APPROVED BY NAPE PHONE E WITH AREA CODE <br /> T�.L(� a <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRRALCCTS SUPERVISOR-DISTRICT CODE BU SINESSPLANFILED DAT5 FI <br /> LPO <br /> O I 2�• bV 323 YES ❑ NO 2-1 S / <br /> CNECK E PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT E BY . � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST' 'R MORE TANK PERMIT FORM 'S'APPLICATION(S), L' SS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />