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STATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD <br /> A <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM V a. �o <br /> SITE ii FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> J� COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7_EUIUAWITLY CLOSED SITE F"a <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE —4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) W <br /> CJ1 <br /> FACILITY/SITE NAME iqLA d DELI I CARE OF ADDRESS INFORMATION <br /> 0550 <br /> ADDRESS NEAREST CROSS STREET ✓9oxmnitae ❑ PARTNERSHIP ❑ STATEAGENCY <br /> IV <br /> t ❑ CORPORATION 11LOCAL AGENCY D FEDERALAGENCY <br /> 12, 11INDIVIDUAL ❑ COUNIYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA s' 3 <br /> TYPE OF BUSINESS: ❑ 2 RIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION Or #of TANK'a <br /> ❑ I GAS 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#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME �y T CARE OF ADDRESS INFORMATION <br /> QivV-2 !M1� •.I� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE it,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME ^ CARE OF ADDRESS INFORMATION <br /> 411A f <br /> MAILING or STREET ADDREESSSS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k,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. if ❑ 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 N JURISDICTION K AGENCY# FACILITY ID% #of TANKS at SITE <br /> ml 10o 1 Z4 = obG <br /> CURRENT LOCAL AGENCY FACIL TY ID M APPROVED BY NAME PHONE IN WITH AREA CODE <br /> 7 Z, �(o <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISORPISTRI CODE BUSINES YES <br /> SNFIED <br /> ❑LED NO ❑ DATE FILLj PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# 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 ON <br /> FORM A(3-2-58) <br /> DATA PROCESSING COPY <br />