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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />a <br />COMPLETE THIS FORM FOR EAC ACILITYISITE <br />MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLO E <br />ONE ITEM 0 2 INTERIM PERMIT F --i 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE 9 <br />I. FACILITYI51IL INI-UKMA IIUM a tivunwa-( <br />--•--, <br />PHONE A WITH AREA CODE <br />DAYS: NAME LAST. FIRST) <br />k <br />NAMEOFOPERATOR <br />�n^{ f <br />OBA OR FACILITY NAME 4 <br />L <br />_ IA <br />W - <br />`� bn.bind¢ O INOIVI <br />NIGHTS: NA!ME(LAST, lH.I <br />L <br />4 WITH AREA CODE <br />NEARES CROSS S REET <br />PARCELN(OPTgNAU <br />ADDRESS <br />,P,H/ONE <br />UN -44-7 <br />PHONE 4 WITHAREACODE <br />O <br />STATE ZIP <br />SITE PHONE# WITH AREA CODE <br />CITU NAME <br />�CODrE <br />CA -l.� •,7 <br />T•� <br />�'/ <br />POxI� CORPORATION 0 INDIVIDUAL PARTNERSHIP <br />Q LOCAL -AGENCY (] COUNTY -AGENCY <br />O STATE.AAGGEEN-C`Y FEDERAL WANCV <br />TOINDICATE <br />DISTRICTS <br />✓ IF INDIAN <br />4 OF TANKS AT <br />SITE <br />E. P. A. 1. D. 4 (optima) <br />TYPE Of BUSINESS T GAS STATION 2 DISTRIBUTOR <br />a o <br />RESERVATION <br />cc <br />O 3 FARM Q 4 PROCESSOR 5 OTHER <br />OR TRUST LANDS <br />J <br />nnunow AOVt <br />(SECONDARY) • optional <br />......._.. <br />FMERGENCY CONTACT PERSO <br />N <br />, <br />PHONE 4 WITH AREA CODE <br />YS: NAME (LAST, FIRST) <br />PHONE A WITH AREA CODE <br />DAYS: NAME LAST. FIRST) <br />k <br />-7-2— <br />�n^{ f <br />r-tLc <br />_ IA <br />rN'IGH <br />`� bn.bind¢ O INOIVI <br />NIGHTS: NA!ME(LAST, lH.I <br />L <br />4 WITH AREA CODE <br />TS: NAME (LAS T, FIRST) <br />PHONE 4 WITH AREA DE <br />IAe1 t t G77 -.A � <br />,P,H/ONE <br />UN -44-7 <br />PHONE 4 WITHAREACODE <br />_______. _.._.__...-��...�...., n.un�n�nnueae nl <br />it. i-mv1'CrT I T vn'nGn lnrvnmw <br />L <br />CARE OF ADDRESS INFO MATIN <br />NAWE <br />CARE FADDRESS INFOR ATIOyN <br />�n^{ f <br />✓ boxblMkab INDIVIDUALf� <br />CORPORATION M PARTNERSHIP <br />AL <br />MAILINGORSTREE ADDRESS <br />`� bn.bind¢ O INOIVI <br />LOCALAGENCV OSTATE-AGENCY <br />.I•�" <br />O - v <br />CORPORATION 0 PARTNERSHIP <br />= COUYAGENCY FFDEMLAGENCY <br />M <br />CITU NAME <br />STATE ZIP CODE <br />PHONE 4 WITHAREACODE <br />! Q(O <br />TANK OWNER INFORMATION - (MUST BE COMPLETED <br />NAMEOFOWNER/ <br />L <br />CARE OF ADDRESS INFO MATIN <br />MAILING OR STREETADDRESS <br />S <br />�n^{ f <br />✓ boxblMkab INDIVIDUALf� <br />CORPORATION M PARTNERSHIP <br />LOCAL -AGENCY STATE-AGENCY <br />O COUNTY41GENCY FEDERAL -AGENCY <br />CITY NAME <br />- <br />STATE <br />ZIP <br />PHONE 4 WITH AREA CODE <br />�CODE <br />7--716 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER • Call (916) 739-2582 if questions arise. <br />TY410� 4 T 4 - <br />V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner Unless box I or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. L-] II. [A III. 0 <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />UAI'19 <br />L <br />OWAL AGENCY USE ONLY " W f- `N\v�% 3' <br />COUNTY# JURISDICTION# FACILI �y <br />p G'P qA l <br />LOCATION CODE- OPTIONAL CENSUS TRACT#-OPflONAL SUPVISOR-DISTRICT CODE -OPTIONAL /✓ <br />y��y9 <br />© a c� a a— /j <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE IN RR NLY��`•"" <br />CnOW3A2 <br />FORM A (S-eD) ( � fes_ .. .. <br />