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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORMW: UNDERGROUND STORAGE TANK PROGRAM ^ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME 3 CARE OF ADDRESS INFORMATION <br /> & (3 t YV1YN1 A O <br /> ADDRESS NEARESTC OSSSTREET ✓BmbNtloi, 0 PARTNERSIIP 0 STATE-MBO <br /> ° A ON ° El PE�RLLMNN3osat <br /> CITY NAMo So <br /> STATE ZIP CODE E SITE PHONE N,WITH AREA CODE <br /> N CA 5–K• - .Z- / <br /> TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box it INDIAN EPA 10 N <br /> RESERVATION orN of TANK'S <br /> ❑ I GAS STATION ❑ 3 FARM El OTHER TRUST LANDS ❑ 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 /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> H. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �lPoc 6fa A62/2 KS so�ra7rS <br /> MAILING or STRWT ADDRESS ✓Box to intlicale 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> D. ,O <br /> / o 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> � C ON C 5�13 <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> QS <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 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. v 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 N JURISDICTION R AGENCY N FACILITY ID E R of TANKS at SITE <br /> 3 / <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> u3r <br /> PERMIT NUM ER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N WPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> I .<3,30 2 5— YES ❑ NO ❑ / C— Q <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: 1� <br /> C v <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'Bl APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. r� <br /> FORM 3-2-88) V <br />