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STATE OF CALIFORNIA'' WATER RESOURCES CONTROL BOARD <br /> _ I <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM � Z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE OI <br /> I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) c <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> N. SM <br /> ADDRESS NEAREST CROSS STREET r✓ idrsk 0 PARTNERSHIP 0 SIAIE AGI <br /> CNTEii�R\SE 'i '"o�PFnON ❑ LOCALAGFNCY 0 FEDRIA4AGDO <br /> �Z,S 0 INDMDUAL 0 COUIYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE x.WITH AREA CODE <br /> CA GSzo�1 (7.Ca -14 <br /> TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID x <br /> ❑ Cs <br /> 1 GAS STATION ❑3 FARM 5 OTHER RESERLANDSVATION or ❑ N of HISTANSITE 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 x WITH AREA CODE <br /> RELF (20a) '4 <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE x WITH AREA CODE <br /> R - _ <br /> II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓ to indicate 0 PARTNERSHIP 0 STATEAGENCY <br /> CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Z5' CAppotgArbO 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x,WITH AREA CODE <br /> S-r qzo4 11 q) <br /> SJ4101 <br /> III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME 11 CARE OF ADDRESS INFORMATION <br /> i L <br /> MAILING or STREET ADDRESS �✓��cHia indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> p ReCORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> {.O..BOX 0 INDIVIDUAL 0 COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE x.WITH AREA CODE <br /> �51W<172A CIA- gS2o <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. ❑ 111. <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 /> COUNTYIN JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> 3 G] g 0 (0 o / <br /> CURRENT LOCAL AGENCY FACILITY IDN APP OVED BY NAME PHONE N WITH AREA CODE <br /> A4 D <br /> PERMIT NUMBER PERMIT APPROVAL DATE IPE IT EXPIRATION DATE <br /> LE <br /> CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FI ID <br /> YES NOPERMIT 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 IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(3-2-SS) `. <br /> '�%' DATA PROCESSING COPY <br />