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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'A': �• <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 1 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> R CAL afligA46-f— co. <br /> ADDRESS NEAREST CROSS STREET ✓SsbMob ❑ PAIiTW" ❑ STATE AGBKY <br /> / 00 E - 7'4 N'- 5'i—. STi4EE`(� ❑ "ATI' ❑ LGGL 488 ❑ IEGER,L.AGDc, <br /> CITY NAME 13MMMUK ❑ cmmAGENLY <br /> STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> -S-�I4 CA <br /> TYPE OF BUSINESS: y DISTRIBUTOR F-1 1 PROCESSOR ✓Box it INDIAN EPA 10 N <br /> RESE❑ I GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYU ND$Or ❑ AT THIS SITE 0- <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 1/4 ot( ( 0 4 3 -o3S/ <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME A•,c CARE OF ADDRESS INFORMATION <br /> SNW"lL 5 5rrg <br /> MAILING o,STREET ADDRESS ✓BOX to inakate ❑ PARTNERSHIP - ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> nVl <br /> 0111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> tNAME SAA4F_ AJS SITE CARE OF ADDRESS INFORMATION <br /> n MAILING o,STREET ADDRESS ✓So.lo,nd,cale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> V` ❑ CORPOUALCN ❑ LOCAL-AGENCY <br /> COUNTY-AGENCYAL-AECY ❑ FEDERAL-AGENCY <br /> INDCITY NAME STATE ZIP CODE PHONE N,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. El 111.❑ <br /> iIt THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> Q APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE <br /> Q LOCAL AGENCY USE ONLY <br /> C <br /> COUNTY N JURISDICTION N AGENCY* FACILITY IDN M of TANKS EI SITE •' <br /> EHI 1 o1 o Ii l 0 6I I 1 10-1 <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> \� LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F}LEp <br /> 0 23. 3 Z YES ❑ NO ❑ )F7 <br /> 3 Q/ <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: <br /> E T. <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. L/`\ <br /> FORMA 13-2-881 <br />