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STATE OF CAUFGWSA `•.i <br /> STATE WATER RESOURCES CONTROL BOARD 14 - <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A "�`� ya <br /> COMPLETE THIS FORM FOR EACH F BRE <br /> MARK ONLY 0 T NEW PERMIT ❑ 3 RENEWAL PERMIT CE'S CHANGE OF INFORMATION ❑ 7 PERMOSED SITE, <br /> ONE REM Q 2 INTERIM PERMIT Q a AMENDED PERMIT S TEMPORARY SITE CLOSURE �� <br /> I. FACILITY/SITE INFORMATION S ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME OF OPERATOR <br /> lru c% � !w� _ <br /> ADDRESS NEAREST CROSS STREET PMCEL*(OPrDML) <br /> CIN NAME STATE ZIP CODE SITE PHONE*WITH AREA CODE <br /> v Box cA sem-- a <br /> TO INDICATE CD CORPORATION Q INDIVIDUAL O PARTNERSMP 0 DrTF0=LOCAL-AGENCY <br /> Q COUNTY .AGENCY E3 FEDERAL#GENCY <br /> TYPE OF BUSINESS a T GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDI i T AT E.P.A I.D.s IapfknsO <br /> 3 FARM A PROCESSOR 5 OTHER RESERVA <br /> O OR TRUST 0.S <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGE ON (SECONDARY)•optimal <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAMELAST,FIRST)T) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRSn PHONE*WITH AREA CODE NIOHTS: NAME(LAST,FIRST) PHONES WITH AREA COOS <br /> II. PROPERTY OWNER INFORMATION- UST BE COMPLETED <br /> NAME <br /> 620�le (/ 7� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSo ✓ EM b'vgkaM 0 INDIVIDUAL QALENC <br /> LOC -AGY (]STATE-AGENCY <br /> � �6 /'IDS 01 w O CORPORATION p PARTNERSNP p COuNTY-AGENcv O FEDEwu-AGENCY <br /> CITY NAME STATE ZIP CODEp, PHONE S WITH AREA CODE <br /> S C41- �J <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ImbuwA Q INDIVIDUAL Q LOCAL-AGENCY O STATEAGENCY <br /> a CORPORATIONQ PARTNERS14P Q COUNrY�AGENCY Q FEDERALAGEWY <br /> CITY NAME STATE ZIPCOOE I PHONE*WITHAREACODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739.2582 if queStions arise. <br /> TY(TK) HQ F4-T74 - <br /> (� a <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I s checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTSNAME(P RWTEOASIONATURE) APPLICANTS TITLE DATE MONTWOAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTIONS FACILITY# <br /> � • � C�aT%Lllo <br /> LOCATION CODE -ORTTGAW, CENSUS TRACT* -OPTIONAL SUPVWOR-DISTRICTCOOE -OPTIONAL <br /> N 3d3 C,3 )(6,(9 2i <br /> THIS FORM MUST BE ACCOMPANIED 9Y AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(9.90) FORMaA-R2 <br />