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STATE OF CALIFORNIV WATER RESOURCESCONTRIBOARD <br /> eE^` :bF <br /> P• <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM V :,Ai <br /> yy� m m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EAC AGILITY/SITE �"'��^='" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT lyl 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C OSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N <br /> .p. <br /> FACILITY/SIT ��AA-_M-E ^/( CARE OF ADDRESS INFORMATION <br /> C G L�^�A <br /> ADDRESS //11// //�� .-�/�� ,�I� NEAREST CROSS STREET So loiMiule ❑ PARTNERSHIP Cl STATEAGENCY <br /> /Ob V / Q / /7c-.i.T/V ❑ COrv10UALI0N ❑ CO�AAGENCY GENCY ❑ FEDEM4AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> 11-119W73:-_61!9- CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ I OAS STATION [:] 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION or F-1 <br /> #01 TANK's <br /> ATI SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE At WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAM ^ /p/Y CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRE ✓eo intlicale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> �fB ❑ RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> �( INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAMEn CARE OF ADDRESS INFORMATION <br /> 5 /✓ <br /> MAILING or STREET ADDRESS -/So. ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN 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. ❑ 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 If #of TANKS at SITE <br /> I I I yon & <br /> CURRENT LOCALCY FACILITY 1I A, APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER C•IGG=GG/••�E PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DAT FILE <br /> P 3, � 3 2a YES [j NO 1:1 7 <br /> CmEck# 7ERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT IN 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 ONL <br /> FORM A(3-2-88) • 0 <br /> DATA PROCESSING COPY <br />