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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD — <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - �� to <br /> C <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `�"='e <br /> FMARK,ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ~TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> W <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) CCn <br /> F %,SZN5 Q rnoVj 'T Yhel:l CARE OF ADDRESS INFORMATION <br /> r <br /> ADDRESS NEAREST CROSS STREET ✓Iiotweis ❑ PARMG50P ❑ STATEAGENCY <br /> / n <br /> Cl CORPORATION ❑ LOCALAGENCY ❑ FEDERAL <br /> C45 in <br /> l C, Rte&* - ❑ INDMWAL ❑ COUNTYAGENCYI� <br /> CITY NAME f�-/M STATE ZIP CflQE SITE PHONE p.WITH AREA CODE <br /> CA ((��41` <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ d PROCESSOfl ✓Box if INDIAN EPA ID p pot TANK's <br /> F71 GAS STATION F__] 3 FARM El OTHER TRUSRVLANDS or ❑ ATTHISSITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4.WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE IL 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: I. ❑ 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 p JURISDICTION Al AGENCY# FACILITY ID If If o/TANKS at SITE <br /> ® Liu <br /> FTUl:= o U <br /> CURRENT OCAL AGENCY FACILITY ID p VED BY NAME PHONE p WITH AREA CODE <br /> A � O ) G <br /> PERMIT NUMBEW PER APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATLgN CODE CENSUS TRACT p SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED n AA <br /> I YES NO I —1 —` &.X-) <br /> /CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: <br /> ITHIS 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 /> 1 FORM A(3-2-8B) <br /> \\v' \Aw DATA PROCESSING COPY WANO <br />