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STATE OF CALIFORNI10 WATER RESOURCESCONTROBOARD f Y_ A FORM W: UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 7f COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED$ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Nr ,r `x' Jok 0 ar Jr,� ADDRESS �y s NEAREST CROSS STREET ✓BWNMItak 0 PARTNERSHIP Cl STATE AGENCY CY IS J S J s, N N �G�1 ❑ INDYI)JALION ❑ �TM GECl FEDERAL AGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE L5SrG(IONJ CA 3.20 20 - 89$`—(5 J3 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Boz if INDIAN EPA 10 N Not TANKY 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESETRUSTYLANDS ION or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION IAAJ 11G,Jv(?r Sc-l'1 MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 1 to __� 0 CORPORATION 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY ,5 0c, Wel la 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME . STATEZIP CODE / PHONE N,WITH AREA CODE ,L III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION jfme' �S MAILING or STREET ADDRESS ✓Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. v III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION M AGENCY* FACILITY ID N N of TANKS at SITE ` rJ a / CURRL CAL AGENCY FACILITY IDN APPROVED BY HANE PHONE N WITH AREA CODE M l �� ,EN: IT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE DE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA FLED YES NO �z3.zz 1�K# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM V APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ;�