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STATE OF CALIFORNb( WATER RESOURCES CONTRIe BOARD «;° <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM u <br /> SITE � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �° o <br /> ( I COMPLETE THIS FORM FOR EACH FACILITY/SITE `'���oa�`e <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 LY SITE F"+ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE m <br /> I.FACILITY/SITE INFORMATION <br /> INFORMATIION &ADDRESS - (MUST BE COMPLETED) <br /> w <br /> FACIL� pCARE OFDRESS INFORMATION <br /> l �W�rQES <br /> ADDR 5 NEAT CROSS S EET ✓Ompu ❑ PARN IP 0 STATEAGENa <br /> 0 WWOMTIM ❑ LOCALAGENLY PIL. EIKY <br /> 0 NM'OUAL ❑ CONN#GENA <br /> CITY NAME/ STATE ZI CODE ITE PH NE M.WITH ARFA CODE <br /> Fee I <br /> TYPE OF BL/USIINNNESSSS:I ❑2 D19MMOR ❑�EWR ✓Box if INDIAN EPA O,#A/ - � 'te �ya <br /> ❑ ❑ LTJ TRRUSTTVLANDS ATION or ❑ ,J✓ AT THISITE Op p <br /> 7 GAB STATION 3 FARM 5 OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAW(LAST.FIRST) n PHONE[p WITH AREA CODE DAYS: NAME(LAST,FIRST) P ONE p WITH AREA CODE <br /> /, _( ;01)334Q 710 Ce <br /> NIGHTS' NAME(LAST,FIRST)' -0HONE p WITH AREA CODE NIGryTg NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> 201 7z 7 S7 21 JIA <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> MAILING w STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ED L- ENCY <br /> 0 INDIVIDUAL 1:1 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE PWITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE <br /> OF ApDRESS INFORMATION <br /> 5 LA ry' A <br /> MAILING or STREET ADD/KESS ✓Box to inEioate 0 PARTNERSHIP 0 STATEAGENCY <br /> D0 CORPORATION 0 LOCAL-AGENCY ERA -AGENCY <br /> Nom/ 0 INDIVIDUAL Cl COUNTY-AGENCY <br /> CI NAME STATE ZIP CODE PHONE ITH AREA CODE <br /> 1 L,00& G'� 1 r / <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. ❑ NL <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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION If - AGENCY R FACILITY ID R R of TANKS N SITE <br /> CURRENT LOCAL AGENCY FACILITYID p APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> Wob cl(1-,, <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA FI <br /> 0-'Z/ YES NO <br /> CHECK p PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT k 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 /> FORM A(3-288) <br /> W \w DATA PROCESSING COPY f <br />