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igRo STOIDsI 3rewoed, 1 T _ <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL jOARDL k)Mn� <br /> FORM W: <br /> UNDERGROUND STORAGE TANK PROGRAM � o <br /> SITE r`� FACILITY/SITE, INFORMATION and/car PERMIT APPLICATION <br /> L=� COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Tf�i(VKLE- f 00yS IqC-r�ictu�Gt1;�l1_ <br /> ADDRESS NEAREST CROSS STREET ✓&C.irdicate ❑ PARTNEFUP ❑ STATE-AGENCY <br /> 1940 j�� `��, ❑ CORPORATION ClLOM AGENCY ElFEDEAAL-AGENCY <br /> •r S- / r :-� Cl INDIMUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP OD SITE PI IONE N,WITH AREA CODE <br /> CA I� 7 <br /> _7 <br /> TYPE OF BUSINESS: F__]2 DISTRIBUTOR ❑4 PROCESSOR ✓Box 4 INDIAN EPA ID N <br /> RESERVATION or #of TANK'S <br /> E] 1 GAS STATION [:]3 FARM t t 5 OTHER TRUST LANDS ElAT 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 M WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) ' PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 6�?D9 x'2'3 <br /> I1. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> So`r►e CZ CO3 v yre- <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION &ADDRESS -- (MUST BE COMPLETED) <br /> r� NAME CARE OF ADDRESS INFORMATION <br /> S ,nuc a3 (9-/v <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br />— <br /> CITY NAME STATE ZIP CODE I!! <br /> N.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: 1. 21--11. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY 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 /> [PMERMIT <br /> UNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> E[ <br /> a Q o1:ax <br /> T LOCAL AGENCY FACILITY IDM APPROVED BY NAME PHONE 11 WITH AREA CODE <br /> NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ON CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> I YES NO <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: T <br /> THIS FORM MUSS ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> \ FORM A(3-2 X) 9\\-/ �- <br />