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F'A q <br /> STATE OF CALIFORN A WATER RESOURCES CONTROL. BOARD <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM <br /> z <br /> SITEFACILITY/SITE, INFORMATION and/or PERMIT A ION <br /> COMPLETE THIS FORM FOR EAC!ZCILITY/SITE qq <br /> F—] 3 RENEWAL PERMIT PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ 1 NEW PERMIT [�r5 CHANGE OF INFORMATION ❑ 7 P CA) <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I — , <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> b <br /> FACILITY/SITE NAME T v <br /> NEAREST CROSS STREET Bax to ❑ PART119GHT 0 STATEAGENCY <br /> T <br /> ADDRESS V710N 0 LOM4GENCY Cl FEDERAL-AGDO <br /> L/O Y40 tj [I WUNTY-AGENCY <br /> MA-1/V IVDUAL <br /> CITY NAME Tan& 1 <br /> STATE ZIP CODE SITE PHONE#.WITH A CODE <br /> :7 <br /> -5- a1011CA <br /> TYPE,O,F SINESS: E]2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box it INDIAN EPA ID N #of TANK'S <br /> RESERVATION or ❑ AT THIS SITE <br /> 1 G� <br /> A 5 OThER TRUSTLANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHO WITH AREA COD DAYS NAME(LAST.FIRST) PHOTf�H AREA CODE <br /> ,L,4� _q H <br /> ftT4 Leg D&-Q <br /> PHONE 0 WITH AREA CODE NIGHTS: AME(LAST, RST <br /> PHONE 9 WffH AREA CODE <br /> NIGHTS. NA ( Sl�RST u <br /> __ <br /> --h U=I <br /> E !I L <br /> 11. PROPER4Y OWN INFORMATION &ADDRESS (MUST BE OMP TED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME —T <br /> ali� T_ <br /> V ."clicate 0 PARTNERSHIP ❑ STATE-AGENCY <br /> MAIUNG or STREET ADDRESS kox RPORATION El LOCAL-AGENCY El FEDERAL-AGENCY <br /> V/( INDIVIDUAL Cl COUNTY-AGENCY <br /> STATE ZIP CODE PHONE#,WITH A' E <br /> CITY t1169— 42W <br /> Ill. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> L <br /> Box to indicate El PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS ✓ <br /> CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> El INDIVIDUAL [:1 COUNTY-AGENCYCITY NAME, WITH AREA CODE <br /> STATE I ZIP Cooe PHONE <br /> Slt&ov 2,-4 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> I <br /> CHECK ONE{1)BOX INDICATING <br /> WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. II. El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST 0 F MY KN 0 WL ED G E,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME{PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY 10# #of TANKS at SITE <br /> 0 10 <br /> DiRl I Ld 1 A I <br /> AGE Y FrLITY ID APPROVED BY NAME PHONE#WITH AREA CODE <br /> CURRENT LOCAL 1� p"llf, <br /> F77 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> COPE BUSINESS PLAN FILED DATE FILED <br /> CURRENT <br /> PCA YFL, <br /> T A <br /> w <br /> TT <br /> ER APPROVAL <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT YES <br /> NO <br /> 0 1 CENSUS <br /> 0 q / 9 —1 — — <br /> — SURI FEE CODE RECEIPT BY: <br /> CHECKN <br /> PERMIT AMOUNT SURCHARGEIAMOUNT Avwev <br /> I LYK <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 INFORM <br /> ,*TiON <br /> P7 <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />