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SEP'i;of <br /> uiie�'�f SSA <br /> STATE OF CALIFORNIA • WATER RESOURCES CONTROL BOARD , <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> P <br /> SITE ;,FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION off/ <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM ENTLYC DSITE .O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) Cts <br /> CARE OF ADDRESS INFORMATION <br /> FACILITY/SITE NAME <br /> ✓'miwescae 0 PARTNERSHIP 0 STATE NEAREST CROSS STREET 0 Ba webcaCORPORATIe ❑ LSSALERSHIP 0 SEOD AGENCYC! <br /> ADDRESS SSU I - , / I_ <br /> V v`Nj ❑ INSMWAL ❑ GdJNTY AGFN(,Y <br /> STATE ZIP COD j SITE PHON�WITH ARECO DE <br /> CITY NAME CA <br /> TYPE OF BUSINESS: 2 DISTRIBUTOR 4 PROCESSOfl ✓Box it INDIAN EPA IDN X of TANK's <br /> ❑ ❑ RESERVATION or AT THIS SITE <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE N WITH AREA CODE <br /> DAYS' NAME(LAST,FIRST) PHONE Al WITH AREA CODE DAYS- NAME(LAST.FIRST) <br /> PHONE N WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) <br /> PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓Box to indicate Cl PARTNERSHIP 0 STATE-AGENCY <br /> MAILING or STREET ADDRESS ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> Cl INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> MAILING or STREET ADDRESS 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> CITY NAME <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOT <br /> AND BILLING: I. ❑ If. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION% AGENCY# FACILITY ID X <br /> %ol TANKS at SITE <br /> FEE= F1 <br /> CURRENT LOCAL AGENCY FACILITY ID M <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> )6G�6147 <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED p q <br /> q Z 0 D Ji YES NO � AZO'/ <br /> BY: <br /> CHECK N PERMIT AMOUNT SURCHAR E AMOUNT FEE CODE RECEIPT N <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. r <br /> FORMA(3-2-88) _ <br /> ' � DATA PROCESSING COPY ' <br />