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o� STATE OF CALIFORNIAO WATER RESOURCES CONTR ARD FORM W: UNDERGROUND STORAGE TANK PROGRAM S FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ANENTLY CLOSED SITE '(SNE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 15/ 1 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACIL )SITE NAME r CARE OF ADDRESS INFORMATION ADDRESS c ,„ I - NEAREST CROSS TfiEET ✓Bwl wTI ❑ LOCALA DIC ❑ STATE Jj ❑ cawDMame ❑ PAmu p ❑ rmTE AGE1 +cr ❑ INDVIWAI ❑ OlUN1Y#GRIIX CITY NAME TE ZI CODE SITE PHONE N,WITH AREA CODE CA o 3 G Y—336(, TYPE OF BUSINESS: ❑2 DISTRIB OR ❑4P�ROCESSOR ✓Box R INDIAN EPA ID N N of TANK's RES❑ 1 GAS STATION ❑ 3 FARM XOTHER TRUSTYLANDS Or ❑ AT THIS SRE ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREACODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFOfIMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP - ❑ STATE-AGENCY D CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY O INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDR S — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD SE USED FOR MOTH LE OTIFICATION AND BILLING: 1. ❑ it. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE B T OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION R AGENCY N FACILITY ID N N of TANKS at SITE X33In h 16 10 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA N CODE EN�1 O SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI D C/ ¢C� ov YE NO J ` U / CHE N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: \ THIS FORM MUSTSEAC E(�1(IED BY AT LEAST(1)OR MORE TANK PERMIT FORM'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION7 .V.`A'IORM A(3-2-88) ^ Af"� 'V J