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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5 x' <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 215 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O Q <br /> I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> FACIUTY_ I"TE,NAME CARE OF ADDRESS INFORMATION <br /> a souitiJ <br /> ADDRESS NEAREST CROSS STREET ✓8sbid'uV C PAAf mw C STATE AOR0 <br /> C` ❑ Cowoannav ❑ LOCAL WANLY ❑ FEDEW AGDO <br /> LP V ❑ MBMWAL ❑ COUNTYAGBlp <br /> CITY NAME ^ STATE ZIP CODESITE PHONE N,WITH AREA CODE <br /> CA 5A o Cao FYa-/0A <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID 4 N of TANK'N <br /> RESE <br /> ❑ 1 GAS STATION ❑ 3 FARM THER TRUSTYLANDS or ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> elf/5 ?& I - 7 <br /> NIGHTS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> s <br /> 11. PROPERTY OWNER I ORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate C PARTNERSHIP D STATE-AGENCY <br /> D CORPORATION D LOCAL AGENCY ❑ FEDERAL-AGENCY <br /> C INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> 111. TANK OWNER INFORMATION &ADDRE — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Bax to indicele C PARTNERSHIP C STATE-AGENCY <br /> ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> INDIVIDUAL C COUNTY-AGENCY <br /> CITY NAME STAT 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. ❑ it. ❑ 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 S JURISDICTION R AGENCY N FACILITY ID M S of TANKS at SITE <br /> 10 101 / Ua � DQa <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION C DE CEMBUB TRILCT Y 8UPERVISOR-DISTRICT OD[ BUBINE88 P sN F❑ILED NO <br /> ❑ DA�FILEDvwD <br /> 3 N O(� 3 <br /> \\\ CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-8&)` .r <br />