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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM ,L 'K o SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r C COMPLETE THIS FORM FOR EACH FACILITY/SITE Cy(,Fp MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT Ei CHANGE OF INFORMATION ❑ 7 PERMANE Y CLOSED SITE Z ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACI ITY/SITE NAME CARE OF ADDRESS INFORMATION ue`c a `r� '►p�� ADDRESS NRE TCROSSSTREET ✓Box to indicate ❑ PARTNERSHIP Cl STATE-AGENCY W N ❑ CORPORATION B'OCAL-AGENCY ElFEDERAL-AGENCY3 a /`'[ S y ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME /1 STAT^A ZIP� (�O PHONE WITH AREA CODE TYPE OF BUSINESS: F—] 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA IID'#RESE ✓\IL/^/ ❑ ❑ � TRUST LANDS ATION or ❑ #of HIS SITE 1 GAS STATION 3 FARM THER AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE Cao - o NIGHTS: NAME(LAST,FIRSf) PHONE#VeTH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME � � /Sc ' ^R i CARE OF ADDRESS INFORMATION MAI_GtS�REET ADDRfi)ESS ^� ✓Box to indicate ❑ PP CAL-AGE IP ❑ STATE-AGENCY S' ❑ CORPORATION C7 LOCAL-AGENCY ❑ FEDERAL-AGENCY i ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE T`- , ONE# WITH AREA CODE I2 CIL�� /� ��a D a- a 1 y-10q 7 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION S 19 �� MAILING or STREE ADDRESS V v ✓Box to indicate El PARTNERSHIP ElSTATE-AGENCY El CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ II. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE CURRENT L CA AGENCY FACILITY ID# APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED ") 3 . 9-0 a YES ❑ NO W3B10 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY/ 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. FORMA(3 \ X� I� 0 DATA PROCESSING COPY