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STATE OF CALIFORNIA* WATER RESOURCES CONTROL410ARDS' <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m o <br /> � <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 64 7 PERMANENTLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 4 <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) CD <br /> FACILITY/SITE NAME <br /> G, CA OFADDRESSNFORV/MATTIO <br /> QI/�N 4OO <br /> ADDRS/0NEAREST CROSS STREET IIy <br /> /O <br /> If4 <br /> ✓Bw to wwre ❑ PA NMIP 11 SATE AGDO <br /> IP + o OMOAnON -@ !Q -A 0 11 RMERAL-AGENCY 11 Y Zb �rc <br /> CITY NAME STATE ZIP CODE ITE P NE N,WITH AREA CODE <br /> L�sc7 ati/ CA5330 e2 p7835 169 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4PROCESSOR ✓Box if INDIAN EPA ID It <br /> RESERVATION or /'� (, #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ l„(NFA AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST, RST) PHONE k WITH AREA CODE DAYS: NAME(LAST FIRST IF#WITH!-- ,F <br /> n"fj <br /> ze 1?38-3165 ; <br /> NIGH,T,S,jNAME(LA ST,FIRST) "PHONE#WITH AREA <br /> jCODE PJ16HTS'. NAME(LAST,FIRST) - � PHUrvcx VVIin AREACODE <br /> 5�e( 1Gssell /D I <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAtM�E n CARE OF ADDRESS INFORMATION <br /> EscC.f� <br /> MAILING or STgEET ADDRESS ✓Box to indicate PARTNERSHIP ❑ STATE-AGENCY <br /> S OS ❑ CORPORATION CAL-AGENCY ❑ FEDERAL-AGENCY <br /> V t/ ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITU NAGE STAT ZIP CODE 2OONE# WITH AREA COD / <br /> f 15 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) (bJ J) <br /> NAME 4MFS CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box toinoicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE It,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. ❑ 11. V 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 /> 0021 1 ,6000 <br /> CURRENLO <br /> T CAL AGENCY FACILITY ID# APPROVED-Y NAME PHONE#WITH AREA CODE <br /> �4N G <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATIO CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED r� C <br /> F3 ,gp YES [:] NO 1:1 /f 6O <br /> CHECK# PERMITAMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# se : <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 /> FORMA(S-2-SG) 0 <br /> DATA PROCESSING COPY 9 J <br />