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Ii <br /> ar- <br /> STATE OF CALIFORN O WATER RESOURCES CONTRBOARD /S`�•°�•,"'�F <br /> V. •uA <br /> FORM W: <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> x Pnh �'4 <br /> SITE ;. FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> �! COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑I—EEWAAqNTLY CLOSEDISITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE !( <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDHESS INFORMATION <br /> I e <br /> ADDRESS �. (� NEA F T CROSS ST EET ✓ ion ❑ PARTNERSHIP ❑ STATE-AGENIX <br /> -71 ! 5 o in „ Gi.. i4lti ❑ INGM[UUAL'a' Cl LOCAL-AGENCY <br /> TYTY-AACAWY ❑ FEOENAt-AGENCY <br /> CITY NAME STATEZIP COD SITE PHONE P.WITH AREA CODE - <br /> S7� Zr/r CA _oe- /v!' <br /> TYPE OF BUSINESS: ❑2 DISTRI13VTOR SSOR ✓Bax if INDIAN EPA ID X <br /> RESERVATION or Nal TANK.5 <br /> 1 GAS STATION ❑.3 FARM 5 OTHER TRUST LANpS ❑ AT THIS SME <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PRONE N WITH AREA`CODE— *---46 <br /> r` o U-el � <br /> 0 I <br /> NIGHTS: NAME( ST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> f L/ <br /> IL PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> _ ,® i <br /> NAME 5r f/I Le,5 CARE OF ADDRESS INFORMATION <br /> Go P y* - g_ <br /> MAILING or STREET ADDRESS ! / ox Ia indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �' Z CORPORATION ❑ LOCAL-AGFNCY ❑ FEDERAL-AGENCY <br /> vv ❑ INDIVIDUAL ❑ COUNTY-AGENCY -! <br /> CITY NAME j; STATE ZIP CODE PHONE it,WITH AREA CODE ; <br /> 2-13-173 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY i <br /> © CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> " CITY NAME a STATE Zip CODE PHONE N.WITH AREA CODE <br /> IV. LEGAL.NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t)SOX INDICATING WHICH ABOVE ADORES=SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1• ❑ 11. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT: <br /> APPLICANT'S NAME(PRINTED 3 SIGNATURE) GATE R <br /> LOCAL AGENCY USE ONLY ; <br /> COUrnNTY N1 JURISDICTION M AGENCY M FACILITY ID N M of TANKS of SITE <br /> l�J 101112- 1 (-IljlEEO <br /> d <br /> CURRENT LOCAL AGENCY FACILITY ID 11 APPROVED BY NAME PHONE N WITH AREA CODE,: <br /> PERMIT NUMBER PERMIT.APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT w SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �$ { <br /> YES NO <br /> CHECK I i'.' PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: G„/ <br /> / .i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(Il OR MORE TANK PERMIT FO RM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY..- <br />