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. ..�'ti. _,r �.- �. ,,r-.-..,�-t---r �.. ..-..-..�., . -!-�.. ;,.._moi --'.-.-a - ,ea-...r .�.vr �...ryM'•'�• -•.---•. -_ <br /> STATE OF CALIFORNIN WATER RESOURCES CONTRIPBOARD «yE <br /> Y \A <br /> FORM W: <br /> UNDERGROUND STORAGE TANK. PROGRAM <br /> O . <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION1� <br /> C COMPLETE THIS FORM FOR EACH F CILITY/SITE Cy 4,FORN P <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT EP'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE $J <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE N <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) ~ <br /> 00 <br /> FACIL /SITE NAME CARE OF ADDRESS INFORMATION <br /> * 6 mateviia (s <br /> ADDRESS NEAREST CROSS STREET ✓ xloindic& ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> IC>) t; El CORPORATION ClLOCAL-AGENCY ElFEDERAL-AGENCY <br /> j a v�Ce liIF ❑ INDIVIDUAL ❑ COUNTY-AGE <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WI 15E <br /> S C_ l CA o a La Oct <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 P OCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION or #of TANK'a J <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ��' l P✓`S 4'�2 Q r K C a fes) v-&,v- 5F0D , &t-eQ om `S (j Oct)q&Z -�-o <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 20 - - 21 8 a tie fe <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME /IsCARE OF ADDRESS INFORMATION <br /> Gh m� n <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY LL R <br /> Q INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#,WITH AREA CODE <br /> S C r+ a a� <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ x to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME ` 1 Vv V S�l� ZIP CODE D � PHONE 9,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS (/r <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 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 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> [MI0 [11 -711 � l <br /> CURRENT LOCAL AGENCY F CILITY ID k APPROVED BY NAME PHONE#WITH AREA CODE <br /> C R 6 )- <br /> PERMIT NUM ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA E FILED <br /> �D / YES ❑ NO ❑ S <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT It 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(3-2-88) . 0 <br /> \ DATA PROCESSING COPY <br />