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STATE OF CALIFORNIA- WATER RESOURCES CONTROL-60-ARD <br /> h##� a TM1f <br /> w A <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM m �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT F_� 3 RENEWAL PERMIT 195 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 /> fV <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> t <br /> ADDRESS NEAREST CROSS STREET ✓Am brhsk ElPNRNENBIIP ❑ STATE AGENCY <br /> ❑ IN NON 11LOCALAGENCY ClFEGEPALAGPd <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> 0 * CA 95236 <br /> TYPE OF BUSINESS: El/DISTRIBUTOR ❑4PROCESSOR ✓Bo%#INDIAN EPA ID p <br /> RESERVATION of #of TANK'e <br /> ❑ 1 GASSFATION 2] 3FARM ❑5 OTHER TRUST LANDS ❑ 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 N WITH AREA CODE <br /> NIGHTS NAME(UST.FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> as <br /> MAILING or STREET ADDRESS ✓Bo.to indicate O PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE HONE It,WITH AREA CODE <br /> 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAM / CARE OF ADDRESS INFORMATION <br /> &7 <br /> MAILING or STREET ADDRESS I/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CiR NAME STATE ZIP CODE HONE#,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: I. Rr if. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> l I I I zI &7 101 1010101 > <br /> CURRENT LOCAL A ENC F�ICI Y ID N APPROVED BY NAME PHONE#WITH AREA CODE <br /> Z I& <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> E <br /> DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE ILEDS, 2-3 3 ��r YES ❑ NO PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. (1 <br /> FORM A(3 208) <br /> DATA PROCESSING COPY <br />