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I <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE �'��•�a_"-�" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMA CLOSED SITE I"+ <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE00 <br /> 1 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> MIS <br /> ADDRESS NEAREST CROSS STREET ✓Sox bvwknle ❑ PARTNERSHIP ❑ STATE AGENCY <br /> ❑ CONPORATION ❑ LIMAL AGENCY ❑ FEDERAL AGENCI <br /> a ❑ INDIVIDUAL ❑ WUNTY AGENCY <br /> CITY NAME , STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA a Bio aa9 - 9s <br /> TYPE OF BUSINESS. ❑ p D UTOR ❑ 4 PROCESSOR ✓Box If INDIAN EPA IO a <br /> ❑ 7 GAS STATION 3 FARM 5 OTHER RESERVATION or q ��,. AT THIS SITE <br /> ❑ TRUST LANDS E] /W /K� II <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 /> e ero A APq ' q-50 <br /> NIGHTS'. NAME(LAST, IRST) ii PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS11 LOCAL-AGENCY <br /> �/Y{ / /^�/// ✓Box la indicate ❑ PARTNERSHIP 11 STATE-AGENCY <br /> CORPORATn /VA / J { ,`'�1 11 NDIVOUALION 11 COUNTY AGENCY El FEDERAL-AGENCY <br /> CITY NAME / STATE ZIP CODE PHONE#,WITH AREA CODE <br /> L /9 tJ 1 <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> aS b I <br /> MAILING or STREET ADDRESS -/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.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. ❑ 11. 111. ❑ <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID is #of TANKS at SITE <br /> 0 <br /> CURRENT LOCAL AGENCY FACxLl17Y lilt" APPROVED 8Y NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER ry'1 / PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CE/NS1US TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUIN FILED DATE FILED <br /> O�3• <br /> a ,5 VES NO91 <br /> CHECK# PERYIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# BY: <br /> WTHIS 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. <br /> FORM A(3-2-58) <br /> DATA PROCESSING COPY <br />