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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SITFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> N <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) 0 <br /> 4h0 <br /> FACILITY/SITE NAME © ' 1' ✓ ( CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STj7EET ✓Boa lDinxaW C PARTNUiSHIP C STATE AGENU <br /> n /x , WM I � ❑ INDIVIDUAL <br /> CORPORATION ❑ CM ttA�CY ❑ FEDERAL AGENC! <br /> CITY NAME C� STATE "'' ZIP CODE SITE PHONE N,WITH AREA CODE <br /> CA a d <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PR ESSOR ✓Box if INDIAN EPA ID x <br /> RESERVATION or If of TANK'S / <br /> ❑ I GASSTATION ❑3 FARM OTHER TRUST LANDS ❑ "v v—� AT THIS SITE 1 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> �i oZ0`l 100 - <br /> NIGHTS: NAME(LA T,FIlR-ST_)� I PH E p WITH AREA CODE NIGHTS: NAME(LASE FIRST) PHONE N WITH AREA CODE <br /> S - <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 11,b Cao wam o- Q i <br /> MAILINGor STREET ADDRESS 1 a a ✓Be.to indicate ARTNERSHIP C STATE-AGENCY <br /> ❑ CORPORATION C LOCAL-AGENCY C FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY AGENCY <br /> CITY NAME STATE ZIP ODE PHONE p,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> I . NAMECARE OF ADDRESS INFORMATION <br /> 1^^ <br /> i <br /> MAILING or STREET ADDRESS P1 v ✓Box to indicate ErPARTNERSHIP Cl STATE-AGENCY <br /> C CORPORATION ❑ LOCAL-AGENCY C FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M,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) DATE 1, <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> m 3 191 a 1 1010101 / 1 <br /> CURRENT APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> DwAyul <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> al YES NO 7 g <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N B <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 /> FORMA(3-2-68) \/\) <br /> DATA PROCESSING COPY `+� <br />