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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ / NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION P7 PERMANENTLY CLOSED!SIflTEr ONE ITEM ❑ 2 INTERIM PERMIT ❑0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) Fa W FACILITY/SITE NAI-0E CARE OF ADDR SS INFORMATION ADDRESS �` NEAREST CROS/SS STREET ✓Bmb AeNk ❑ PNRNERSHIP ❑ STATE AGENCY 0/3-/ x> a U, O CGRAGRATION 11LOCM AGENCY ❑ ROEPAL AGENCY ❑ INDIVIDUAL ❑ COUNTY- AGENCY CITY NAME / STATE ZIP CODE SITE PHONE A.WITH AREA CODE o�k C./C hr..'1 CA 95ao-i? - 9 L1 GAS STATION TVP' USINESS. E] 2 DISTRIBUTOR ❑ d P SSOq ✓Box it INDIAN EPA ID a u ❑ 3 FARM OTHEfl TRUSTMLANDS or ❑ ��L— AT THIS SITE 0 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE - NIGHTS NAME NAME(LAST,FIRST) PHONE p ITH 4AhllE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE C/ IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 'elymaA 06 MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATEAGENCY 4/n/ ❑ C9RPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY v INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE e 9S iaY o - 7-017 111. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION .5-as MAILING or STREET ADDRESS ✓Box toind,cate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODEPHONE k,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) PATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION N AGENCY R FACILITY ID# R of TANKS at SITE ail = 1 0 1 0 1 .2EIEE 101010101 CURRENT LOCAL AGENCY FACILITY IO APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS"ACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3 YES NO 7-� HECK* PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. F RM A(3-2-88) I "' 'BDATA PROCESSING COPY r� i