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STATE OF CALIFORNIP WATER RESOURCES CONTROIROARD <br /> W. <br /> FORMW: <br /> UNDERGROUND STORAGE TANK PROGRAM m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> z <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I N W PERMIT F-] 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SED SITE I"a <br /> ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> MS- <br /> ADDRESS NEAREST CROSS STREET ✓ Flo rdrcak ❑ PARTNERSHIP ❑ VATE AGENCY <br /> COR NvIDN ❑ LOCALAGENCY ❑ FEDERAL AGENCY <br /> ❑ INOIVIOUAL ❑ COUNiXAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE <br /> �`� CA p�j - ?/ <br /> TYPE OF BUSINESS: ❑ 2 IISTRIBUTOR ❑I 4 PROCESSOR ✓Box if INDIAN EPA ID a <br /> ❑ ❑ ✓i' TRUSTATION LANDSof ❑ AT THIS SITE <br /> I GASSTATION 3 FARM OTHER <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE X WITH AREA CODE DAYS. NAME(LAST.FIRST) PHONE X WITH AREA CODE <br /> s <br /> NIGHTS: NAME(LAST. ST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME _^ �, CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING or STREET ADDRESS ✓B intlicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ORPORATION ❑ LOCAL-AGENCY C3FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE f.WITH AREA CODE <br /> ­43,12-- <br /> Ill. <br /> 3 LIII. TANK OWNER IN ORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDR SS ✓§�ppHMCCin(licale ❑ PARTNERSHIP ❑ STATE AGENCY <br /> L3!'CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY'AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,WITH AREA 000E <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 R JURISDICTION R AGENCYLIF FACILITY ID R #of TANKS at SITE <br /> 10 16 6c 431 <br /> CURRENT LOCAL AGENCY FACILITY IDX APPROVED BY NAME PHONE X WITH AREA CODE <br /> PERMIT NUMBER PERMIT AP ROVAL DATE PERMIT EXPIRATION DATE <br /> 'D—/2— 7T <br /> LOCATI CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> Z 3, YES NO Q �� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 114 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-88) <br /> DATA PROCESSING COPY 5 <br />