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r� J <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD .E <br /> i5c .... ..�H <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM (&,�' <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `+�,ro�rP I <br /> [MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑p INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ~ <br /> O <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N <br /> FACILITY/SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> Cor p <br /> ADDRESS NEAREST CROSS STREET V,Rw to PA RN 0 PARTNERSHIP 0 GTATE-AGENIY <br /> 3o S. c k rna �/Ne ❑ CORPORATION ❑ LOCAL AGENCY 0 FEDERAL AGENCY <br /> S ❑ RDIV UAL 0 COUNTYACENCY <br /> CITY NAM STATE ZIP CODE SITE PHONE A.WITH AREA CODE <br /> C � CA 52 209-33 <br /> - 67 <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> ❑ I GAS STATION ❑ 3 FARM li,F6THER TRUSTYLANDS ATION or Of of TANK's <br /> ❑ ATTHIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> IiV� zo -3SUKP <br /> NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE NIGHTS NAME(IAST.FIRST) PHONE#WITH AREA CODE <br /> f WQ ✓� 204 -33 -9`N76 UKN <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP IllSTATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S AS <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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. ❑ it. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MV KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION k AGENCY N FACILITY ID# If o1 TANKS at SITE <br /> E O6 1 2- 3 1 0 10 100 <br /> CURRENWWrACILITIG N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> L <br /> OCATIONE CENSUS TRACT N SUPERYI;OR%(STRICT CODE BUSINESSPLAN FOILED No <br /> ❑ 11.4( ///0 <br /> It <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# (•' 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 /> / FORMA(3-2-88) " <br /> DATA PROCESSING COPY `./ <br />