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STATE OF CALIFORA WATER RESOURCES CONTROL BOARD <br /> SEP th <br /> FORM W: e <br /> UNDERGROUND STORAGE TANK PROGRAM ^ <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o <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 C j <br /> ONE ITEM 2 INTERIM PERMIT q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE q •O <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) / W' / <br /> F /SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> ADDRESS I N <br /> �> NEAREST CROSS STREET ✓Ete"dule 0 RAFTIN IF 0 STATE AGENCY M <br /> 0 COR TON 0 LOCFI AGENCY 0 FEDERALAGENCY <br /> CITY NAME 0 INDMWAI 0 COIRITY-AGENCY <br /> T2 STATE ZIP CODE E PHO E#,WITH AREA CODE <br /> CA q Z �R -Z <br /> TYPE OFBUSINESS: �2pISTRBUTOfl �4PAOCESSOq ✓So"INDIAN EPA IDp <br /> 1 GAS STATION 3 FAflIA 5 OTHEA RESERVATION or ❑ #of TANK'# I <br /> TRUST LANDS AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRSTf PHONE#WITH AREA CODE DAYS: NAME(LASTRRST) <br /> PHONE It WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESSINFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 0 CORPORATION 0 LOCAL-AGENCY ❑ FEPERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> GITY NAME <br /> STATE ZIP CODE <br /> PHONE It,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS %/Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY C FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCV <br /> CITU NAME STATE ZIP CODE PHONE p,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: 1 II 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# AGENCY# IDN C #of TANKS at SITE <br /> 5 <br /> CURRENT LOCAL AGENCY FACILITY ID# AP DBY NAME PHONE WITH AREA CODE <br /> IKG 5 <br /> PERMIT NUMBER P OVAL DATE PERMIT EXPIRATION DATE <br /> LOCA CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> DATE FI���� <br /> YES NO I <br /> CNECKR PERMIT AMOUNT SURCHARGE AMOUNT QFEE CODE RECEIPT# <br /> BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST,/')OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATI <br /> FORM A(3-2-88) <br /> 1 1 i �Zi DATA PROCESSING COPY <br />