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... ..., - X=;mt,,.� YSL;��rq ,,,tti"w4;�:., j'�:�9a.�TE';r�r'i<.i �:{'TAey:.:.s'c .,-+�^.y,n;.w( :... �ra�r' �t.'�s•t;f: :a>„=t�,.9a'i� ,��}..�rq��..ey' <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL. BOARD <br /> v \SA <br /> FORM W: �. -,_� -L <br /> UNDERGROUND STORAGE TANK PROGRAM (_ �`� <br /> Ir <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `4=FaaN P <br /> MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 TLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ► <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 10 <br /> FACILITY/SITE NAME <br /> ''ll q CARE OF DRESS INFORMATION <br /> AJ A <br /> ADDRESS IN ` NEARES7 CROSS STREET ✓Box to indicate El PARTNERSHIP ElSTATE-AGENCYN <br /> ❑ CORPORATION ElLOCAL-AGENCY ❑ F ERALAGENCY <br /> ( W A L'iI ❑ INDIVIDUAL ❑ COUNTY-AGENCY ''4 <br /> CITY NAME STATE ZIP ODE ITE PHO E#,WITH AR C <br /> 1 <br /> CODE <br /> 57-0c4t- CA �C ?,off t-01 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 714 PROCESSOR ✓Box if INDIAN EPA ID n <br /> ❑ ❑ RESER LANDS or ❑ #of HIS SITE <br /> GAS STATION 3 FARM 5 OTHER AT THIS SITE h <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERG NCY CONTACT PERSON(SECONDARY) <br /> DAS NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 0-o <br /> NIGHTS: NAM (LAST,FIRSTf PHONE#WITH AREA CODE NIGHTS: AME(LAST,FIRST) PHONE WITH AREA CODE <br /> A, ddb <br /> II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE 01 Ap2RESSINFORMATION <br /> MAILING or STREET ADDR }//6ox to indicate ❑ PARTNERSHIP ElSTATE-AGENCY� CORPORATION ClLOCAL-AGENCY ElFEDERAL-AGENCY <br /> ! 71— <br /> /✓`/ 5 UQ� CEJ El INDIVIDUAL 1-1COUNTY-AGENCY <br /> CITY NAVF STAlf ZIP CODE PHON #.WITH AREA CODE <br /> III. TANK OWNER&FORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OFADDRESS INFORMATION <br /> ALD <br /> M LIN or STR ET ADDRESS ✓ ox to indicate ElPARTNERSHIP ElSTATE-AGENCY <br /> �, , e CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> iy INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY E STATE ZIP CODE J% t ONE y,WITH ARECODE <br /> a.P C <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. ❑ 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# FACILITY ID# At of TANKS at SITE <br /> [ T 01 l1 C, 1 :31d1 1 1"1 U I o 131 <br /> CURRENT LOCAL AGENCY FACILITY ID# AP OVED NAM PHONE#WITH AREA CODE <br /> Ake-os6, i X39k <br /> PERMIT NUMBER PERMIT PPROV DATE PERMIT EXPIRATION DATE <br /> a 14lL <br /> LOCATION CODE CENSUS TRACT# SUPERVI OR-DISTRICT CODE BUSINESS PLAN FILED DAT FILED <br /> O U C l YES F-1NO ❑ 7 n�� <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> �I'`� DATA PROCESSING COPY \ <br />