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STATE OF CALIFORNI# WATER RESOURCES CONTRARD P y'" ,0`'"r"� <br /> FORM W: <br /> UNDERGROUND STORAGE TANK PROGRAM � m <br /> SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ,, <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE At"OR" <br /> MARK ONLY ❑ f EW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE Q z <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) - I <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ell Food Inar v <br /> ADDRESS NEAREST CROSS STREET ✓ Dindicale ❑ PARTNERSHIP ❑ STATE-AGENCY r <br /> /�,(� CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY 00 <br /> 013 El r a fF/7,` ❑ INDIVIDUAL ❑ COUNTY-AGENCY , ,� <br /> CITY NAME STATEPDE SITE PHONE#,WITH AREA CODE <br /> G le4vv� CA o�0 ao 9 -/3// <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> 1 GAS STATION ❑3 FARM ❑5 OTHER TRUSTVLANDS or ❑ vL AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If-ufz 3 (a 6q)I4t3-131I L r I A091) tf76- 140 <br /> NIGHTS: NAME( .ST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS ) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 2 I lCom1pa n <br /> MAILING or STREET A RESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br />'I <br /> Of yff�o ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> na he- i �l 8G3 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> s owner <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> NA <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. if. ❑ 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# #of TANKS at SITE <br /> E / I 0E oe � � <br /> CURRENT LOCAL AGENCY FACILITY ID# AP ROVED BY NAME PHONE#WITH AREA CODE <br /> L � 3 <br /> PERMIT NUMBER PERMIT APPROVAL D PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT SU ERVISOR-DIST ICT CODE BUSINESS PLAN FILED DATE FILED <br /> © YES NO <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(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> DATA PROCESSING COPY <br />