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STATE OF CALIFORNIA ' WATER RESOURCES CONTROL BARD 'f '""`" '` <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM �o Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 10 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c""OPS"� <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAVNUj.C6G4KD SITE F4 <br /> ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 3 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS NEAREST CROSS STREET ✓Bmb ❑ LOCAL BDNP ❑ STATE HGERAGENCY <br /> AGEN <br /> I' ❑ TION Cl COUNTY <br /> LAGEEN ❑ fFDEPAI-AGENCY <br /> /3 !2 347 Al, -e9loQltie_ a[s NOMOUAI ❑ COUNIYAGENCY <br /> CITY NAME / - STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> /nodi CA qs opg0 <br /> TYPE OF BUSINESS. ❑ p BUTOR ❑ 4PROCESSOR ✓Box d INDIAN EPA ID N _ �/ N of TANK s <br /> E:1 I GAS STATION [03 FARM ❑ SOTHER TRUSTYLANDS ESERATIONor❑ Ux_ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> S .TF %k <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION _ <br /> MAILING or STREET ADDRE ✓Box r!i°ate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ..n PORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE <br /> c9 I qsa I <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME `1 N CARE OF ADDRESS INFORMATION <br /> S 4' <br /> MAILING or STREET ADDRESS ✓Box to i - e ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ RATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> NDIVIDUAL Cl COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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. ❑ It. 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY R FACILITY ID X N of TANKS at SITE <br /> 1610 10 1Y <br /> CURRENT LOCAL AGENCY FACILITY IO N APPROVED BY NAME PHONE 4 WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CEN TRACT k SUPERVISOR-DISTRICT CODE BUSINESS%SN FILED NO ❑ DATE FIL73 <br /> CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> W <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO RM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-SB) <br /> DATA PROCESSING COPY <br /> l <br />