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1 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAMe <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `C 1110""`e <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION vi 7 P LY SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE �� z <br /> iO <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> F LITY/SITENAME CSA F FAIDDRESS INFORMATION N <br /> ADD SS NRESTT��C,ROSS STREET ✓ ,to irgiUR ❑ PAflTNERSIHP ❑ FATEACENCY <br /> CORPORATION ❑ LOCAL-AGENCY [3 FEDERAL <br /> Itl <br /> ❑ INDIVIDUAL ❑ COUNTY AGENCY <br /> CITY NAME STATE ZIP C0QLSITE PHONE k,WITH AREA CODE <br /> CA Is Oq '/ <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓30x0 INDIAN EPA ID a <br /> ❑ 1 GAS STATION [—] 3 FARM OTHER TRUER LANDS RESEor ❑ Mol TANK'N D O <br /> AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMEFiGEW CONTACT PERSON(SECONDARY) <br /> EI NAM RST) HON# H AREA CODE DA�'. AffE(LAST.FIRST) P E#WITH AREA CODE <br /> F/�b <br /> NI S. NAME(LAST, RST) PHONE N WITH AREA CODE NIGHT NAME(LAST,FIRST) E N WITH AREA CODE <br /> 9 S <br /> 11. PROPERTY OWVIIER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAM CAREVD SS INFORMATION <br /> MAI N or TREET ADDRESS ✓ ox to intlicale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> g CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CIN NA E STgJE ZIP E♦ PHONE tt 1^ATH AREA CODE <br /> Sl <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) /,/~� T/'�� <br /> NAME CA DDRESS INFORMATION <br /> MAILING rSTREET ADDRESSxto intlicale El PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY EIFEDERAL-AGENCY <br /> .INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NA S STAT ZIP COD PHOry a kH AREA CODE a`1 r[jTl <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. 11. ❑ 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 R JURISDICTION M AGENCY M FACILITY IDM N of TANKS at SITE <br /> m /7FTF] 0 O C) I b <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> 6 /AJ6 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ICHLECK* <br /> ODE CENSUS TRACTM SUPERVISOR-DISTRICT CODE BUSINESS <br /> S N FILED NO ❑ DA EF D -/ <br /> P RMIT AMOUNT SURCHARGE MOUNT FEE CODE RECEIPTNBY: <br /> HIS 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 /> M A 132-SSI C <br /> '� DATA PROCESSING COPY 1\1 <br />