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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �r <br /> SE"uii J"p <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �; o <br /> Tl COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 PERMIT F—] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F'a <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I Q w <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> hf-vf-ou t) S14 9 — M <br /> ADDRESS II`` 1 NEAREST CROSS STREET ✓ ❑ PARTERSHIP ❑ STATEAGEIC <br /> 1 V 3 W - I I r� o COM ATIIGN 0 LU)A� ❑ FIDERk-AGENCY <br /> CITY NAME STATE ZIP CCY <br /> ODE SITE PHONE N.WITH AREA CODE <br /> CA 53 7 <br /> TYPE OF SINESS: ❑2 DISTRIB R ❑4 PROCESSOR ✓Box if INDIAN EPA 10 p If of TANK's <br /> 1 GAS STATION ❑3 FARM ❑ 5 OTHER ATION <br /> TRUST RESERLANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) I PHONE k WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> ese 5 S- oo ilI Is z -�iSkl <br /> NIGHTS: NAME(LAST, STI HONE N WITH AREA CODE NIGHTS: NAME(IFA9F FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> bY� <br /> MAILING or STREET AD((DR��ESS ✓Rantlicate ❑ PARTNERSHIP IDSTATE-AGENCY <br /> P• U 170 / I I ORPORATION ❑ LOCAL-AGENCY F] FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME V <br /> /�'',^, STATE /^� ZIP <br /> (CODE -� PHONE N,WITH AREA CODE <br /> C C A- l�f� -! <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓8ox lolndicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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: 1. 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) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION X AGENCY N FACILITY ID N R of TANKS BI SITE <br /> 3 � = = lqlohFTF,?_T(0o00 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> U <br /> PERMIT NUMBER PERMIT APPROVAL DT TE/ PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACCjTN SU RVIS DISTRICT CO BUSINESS PLAN FILED DATE <br /> FILED <br /> /� ^ <br /> t) p�3-O O [i/ YES NO I N U Oy/ <br /> CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: <br /> 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. <br /> FORM A(3-2-SS) I �l <br /> lwr DATA PROCESSING COPY 5 <br />