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STATE OF CALIFORNIA WATER RESOURCES CONTRBOARD <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION -� <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERM ED SITE Z <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / •O <br /> 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) CAS <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS /� /� NEAREST CROSS STREET ✓Be[IOmeirare 0 PARTNERSHIP 0 STATE AGENCY W' <br /> 9� / (/ N r ❑ CORPG,ION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> [NYINDMDUAL 0 COUNTY AGENCY <br /> CITY NAME A STATE ZIP CODE SITE PHONE H.WITH AREA CODE <br /> F•/YIW-N- CA <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR I ✓GOx if INDIAN EPA ID M �t.,,� �� , <br /> ❑ 1 GAS STATION 3FAgM ❑ 50THER TRUSIf of TANK's <br /> TVLANDS ATION OI ❑ ATTHISSITE O <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Cao9) Rsl- 5 61 7 PHONE p WITH AREA CODE <br /> YvllncP� S . <br /> NIGHTS: NAME(LAST,FIRST) PHONE H WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S &�- <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> VVv, . S , VVl-crt rw.�o <br /> MAILIN: STREET ADDRESS �✓, Box P�,d Cate Cl PARTNERSHIP Cl STATEAGENCY <br /> /. sl r!• �' / "„ n/) /I(` E3 f.QRPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CNYINDIVI DUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE q,WITH AREA CODE <br /> C� ao �aD4 2S) � 17 <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> cv.J-. gr�l>~-UPJ <br /> MAILING or STREET ADDRESS ✓Box to onohcale 0 PARTNERSHIP 0 STATEAGENCY <br /> ❑ CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCV <br /> CITY NAME STATE ZIP CODE PHONE a,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. 19 1L ❑ 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) GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# AGENCY# FA If of TANKS at SITE <br /> 4I -L � D D O � <br /> CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE N WITH AREA CODE <br /> ofz A to <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACTM SUPERVISOR-DISTRICT CODE BUSINES,PSNFILED NG ❑ DAT FI� �D V/'/]_ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT At BY: <br /> i THIS FORM MUST BE ACCOMPANIED BY AT LEAS*R MORE TANK PERMIT FORM 'B'APPLICATION(S), Ulf THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) • <br /> DATA PROCESSING COPY <br />