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a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �/ COMPLETE THIS FORM FOR EAC FACILrTY/SITE <br /> MARK ONLY ❑ 3 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FA Ty E NAME OF OPERATOR <br /> ADD SSS V✓ x ��� NEAR 'loss ST EET PARCEL 9(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SI PHON # HH AREA CODE <br /> G'r D< CAI/ BOX <br /> ZED <br /> TO INDICATE O CORPORATION INDIVIDUAL PARTNERSHIP [=3 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Ea<CAS STATION ❑ 2 DISTRIBUTOR I ❑ ✓ IF INDIAN It OF TANKS AT SITE E.P.A. I.D.A(optimal) <br /> RESERVATION <br /> O 3 FARM ❑ 4 PROCESSOR = 5OTHER Oq TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAV NAME(LAST,FIRST) PHONE A WI REA CODE DAYS: NAME(LAST,FIRSn <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> Nt* -/ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS / ✓box b indicate E:j INDIVIDUAL 0 LOCAL AGENCY [D STATE-AGENCY <br /> D �W7�s•k'I �� CORPORATION [I] PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY <br />