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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 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAMECARE OF ADDRESS INFORMATION <br /> o� l�esfs�P N <br /> ADDRESS NEAREST CROSS STREET ✓RmbYtluk ❑ PARTNERSHIP ❑ STATE AGENCY <br /> CMO.2 33 S. L/ac .� O IINDMDRATION ClUM DORM AGENCY ❑ FEGEALL-AC,ENCI <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> Pf N CA 536 <br /> TYPE OF BUSINESS ❑2 DISTRIBUTOR ❑d PROCESSOR I '/Box if INDIAN EPA ID p <br /> RESERVATION or S of HIS SI <br /> ❑ I OAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e � Z <br /> MAILING or STREET ADDRESS t/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 /> e rs T <br /> MAILING or STREET ADDRESS ✓Box tcind,cate ❑ 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 WNICN ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ 111. ❑ <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 R AGENCY k FACILITY of TANKS at SITE <br /> CURRENT LOCAL AG/ENCY FACILITY ID N PROVED BY NAME PHONE N WITH AREA CODE <br /> G <br /> PERMIT NUMBER P75j; <br /> PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT F BUSINESS PLAN FILED DATE FILED <br /> YES NO �CHECK N PERMIT AMOUNT FEE CODE RECEIPT N 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-BB) <br /> � \1 <br />