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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM e <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION w ; , to <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTI CLOSED SITE I"N' <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME �� CARE OF ADDRESS INFORMATION <br /> 87- <br /> ADDRESS N AREST CROSS STREET ✓Bm toMale ❑ PART ASHIP ❑ STATE-AGEN9 <br /> ❑ CORPORATION ❑ LOCAL AGENCY ❑ FE <br /> A-Z$ ' �U�. El INDIVIDUAL ❑ COUNTYAGENCY <br /> EAAbPGENCY <br /> CITY NAMESTATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> CA 6a09 5R - 3 /93 <br /> TYPE OF BUSINESS: ❑ 2DI TRIBUTOR ❑ 4PROCESSOR '/Box if INDIAN EPA ID N � I^^ ^ Not TANK's <br /> ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRUSTVLANDS ATIONo❑ / W r�-1... AT THIS SITE 0 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DZbNAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(I-AST,FIRST) PHONE#WITH AREA CODE <br /> ip s+s f e q Rn lo t E, Ca sq -3 173 <br /> NIGHTS: NAME(LAST,FIR ) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N 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 ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK 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 ❑ 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: I. ❑ it. ❑ If.❑ <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# JURISDICTION R AGENCY# FACILITY 10# K of TANKS at SITE <br /> -� D I --) (p 1 161010101 <br /> CURRENT LOCAL AGENCY FACILITY LAPPROVED PHONE N WITH AREA CODEPERMIT NUMBER PERMIT APPROVAL DATEIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRINES,PS QFILED NO ❑ OATEF g�VVija3 . a3CHECK# PERMIT AMOUNT SURCHARGE AMOUNRECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)94 MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-8S) 1 C <br /> `�'`'v DATA PROCESSING COPY '-fit'.0--sal' /\ <br />