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YF <br /> i <br /> STATE OF CA <br /> LIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM W: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION '° <br /> COMPLETE THIS FORM FOR EACH ILITY/SITE `��r�oR `" 1 <br /> MARK ONLY ❑ } NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1__lz_EEaLllANjNTLY etDSFD SITE ¢--i <br /> ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) i <br /> FACILITY/SITE NAM P I)fvN rpt CARE OF ADDRESS INFORMATION Cn <br /> C. <br /> ADDRESS NEAREST CROSS STREETra9o� 1:1PARTNERSRP ❑ STATE-AGENCY <br /> i.+ &lAv Df?- I�AT1pM ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 1 <br /> ElINDMDUAL 11COUNTY-AGENCYCITY NAME C /[/ STATE I' ZI COQ_ SITE PHO k.W TH Afl CODE <br /> J �( /Y CA I�//1 �� YGOD <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 ROCESSOR EPA ID N <br /> ❑ 1 GAS STATION ❑ 3 FARM g OTHER T✓Boxit INDIANRUST LANDS of ❑ AT THIS SITE / <br /> EMERGENCY CONTACT PERSON(PRIMARY) _j <br /> EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LA T,fIRSTy PHONE g WITH AREA CO� DAYS: NAMF.(L�FIRS�T)j�.y PHON�NIT y WAREA CODE <br /> IIIy�� <br /> NIGHTS: NAME(LAST,FIA } PHONE N WITH AREA CODE NIGHTS. NAME( T, -iRSTI PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME <br /> P � � CARE OF ADDRESS INFORMA7ION <br /> - _ S721�Gi4c� �rL <br /> MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 2 ✓ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> VV 09, ❑ INDIVIDUAL C3COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#,WITH AR C DF <br /> ��� � Q O <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME' CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE I+,WITH AREA CODE <br /> I <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. IL ❑ 11l. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANO CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> U �1/719 k? Is ago <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE If WITH AREA CODE i <br /> QST 23 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 1 <br /> LOCATION ODE CENSUS TRACT t SUPERVISOR-DIS ICT CODE BUSINESS PLAN FILED DATE FILED <br /> l o ' YES NO Z_34? <br /> I <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT d <br /> i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FOR M `Br APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. E,' <br /> � FORM A 13-2-88) <br /> 1 <br /> DATA PROCESSING CORY <br /> =" <br />