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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD yo. <br /> /W�• sa <br /> FORM W: <br /> M UNDERGROUND STORAGE TANK PROGRAM At, <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLE`I'r ..HIS FORM FOR EACH FACILITY/SITE �C 510RI'p- <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEYV,­PERMIT ❑$5 CHANGE OF INFORMATION ❑ 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 /> A/r lMl,a. Ivzo <br /> ADDRESS �7 G NEAREST CROSS STREET ✓Boz tontine ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> El la. El I DIVIIDDAL� ❑ CAUNIY-AGENCY[1 LOCk-AGENCY ❑ FEDERAL-AGENCY <br /> CITY NAME STATE CZISv ,SI �E#.WITH AREA � <br /> � <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box it INDIAN EPA ID# AN <br /> C ❑ ❑ RESERVATION <br /> RUST LANDS or ❑ #01 HIS SITE GAS STATION 3 FARM 5 OTHER AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION & ADDRESS — MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> A(a5 <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> �^ / / ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ��CJ ZjL L- GG�c�dGv/��ly ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> c (7kwq) - y8 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> /"'CGS � �C��(✓F-� �'� <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> No �prCs�/�� ❑ CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> L ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STA ZIP <br /> _PHONE# REA CODE <br /> / 1 ' � ,� � <br /> /G� `7 �/ <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. ❑ 11. 2 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> ® <br /> 1977T <br /> ! 1C) 0 ]# 1 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA FILED <br /> 01 '�� 9D �`v YES ❑ NO ❑ 7j Lg1 e <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> �1\ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST -T MORE TANK PERMIT FORM 'B'APPLICAi10N(S),US THIS IS A CHANGE OF SITE INFORMATION ONLY.I^ <br /> FORM A(3-2-88) v l <br />