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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD r. <br /> FORM `A': d <br /> SITE UNDERGROUND STORAGE TANK PROGRAM _ o <br /> FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH 5hC LITY/SITEMARK <br /> ONE ITEM ONLY <br /> 1NEW PERMIT 3RENEWALPERMIT 5 CHANGE OF INFORMATION PIE_ NTLY CLOSED SITE <br /> LI <br /> 2 INTERIM PERMIT 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE •Q <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME � SAO CARE OF ADDRESS INFORMATION <br /> / <br /> ADDRESS G NEAREST CROSS STREET ✓AmpnCiok 0 pwNEASIIP 0 9ATEAGENLY <br /> / o S ❑ ImiPm�NWWAL ❑ �AG <br /> IJ LOCk ENCY ❑ FEGEWAGEWY <br /> CITY NAME ENCY <br /> STATE <br /> ZIP CODE <br /> SITE PHONE k.WITH AREA CODE <br /> CA <br /> 9 s' <br /> TYPE Of BUSINESS: 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID N <br /> RESE1 GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS VATION or ❑ A of TANK•a <br /> A7 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 p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N 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 ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to Indicate 0 PARTNERSHIP 0 STATE AGENCY <br /> ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.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 0 FEDERAL-AGENCY <br /> ❑ INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE N.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: I. II. ❑ III. E] <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 A JURISDICTION A AGENCY A FACILITY ID A A of TANKS at SITE <br /> Ml = = IQIQsot 00101 <br /> CURRENT LOCAL AGENCY FACILITY IDAAPPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENS�UAS T'RACTJy( _ SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE FILED 7 <br /> /� !/ J �4✓ f YES NO E] <br /> CHECK k PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: Q <br /> C <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 />