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STATE OF CALIFOR& WATER RESOURCES CONTOL BOARD <br /> FORMW: <br /> : UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �,/ * I(: <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEWVERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE .`�� cn <br /> N C4 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) a) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> crmclpj Mf G 4wrX, So�v�Nr✓ <br /> ADDRESS n D L NEAREST CROSS ST EET ✓DmbNrale 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 CO50 1- R G�k �' S 0 INDIV�IDUALroN 0 COUNTY AGENCY Cl FEDERAL AGENCY <br /> 9 <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> SOC +mNj CA fi330- �zy ^O� <br /> TYPE OF BUSINESS: [:]2 DISTRIBUTOR 4 PROCESSOR ✓BOX if INDIAN EPA ID N ESEp of TANK'# <br /> ❑ 1 GAS STATION E]3 FARM ❑ 5 OTHER TRUSTVLANDS ATION OT ❑ 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 FI ) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> r6cLc e 20-4-823--30W <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 00 lu�b" CD lci $'o~+civ 'Pn/ <br /> MAILING o,STREET ADDRESS ✓ ax to intlic le ❑ PARTNERSHIP 0 STATE AGENCY <br /> CORPORATION 0 LOCAL AGENCY 0 FEDERAL-AGENCY <br /> P, O O'k INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> o ?L�lD I <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e 4s <br /> MAILING or STREET ADDRESS ✓Bax io intlicale 0 PARTNERSHIP 0 STATE AGENCY <br /> 0 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. ❑ 11. 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# JURISDICTION N AGENCY# I�� /��(�y�FAC/�ILIT-Y IIID kD #of TANKS at SITE <br /> HEI�L...:. I. 1 1 / 1 / IC/ I <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE Al WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED �/� <br /> 3,7,,(-- YES ❑ NO ?6 J'! <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: <br /> [� <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. <br /> FORM A(3-2-88) <br /> 1 DATA PROCESSING COPY <br />