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'ssoun � <br /> STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL 90ARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �e <br /> �-4non Y✓ <br /> COMPLETE THIS FORM FOR EACH FACILRY)SITE <br /> MARK ONLY Q 1 NEW PERMIT Q 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 5 TEMPORARY SITE CLOSURE SQ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAMEOFOPERATOR - <br /> rw L /S <br /> ADDRESS 1j NEAREST CR SS STREET PARCEL UPTONAL) <br /> 1A90 r, Ckckr <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> T BOX O CORPORATION Q INDIVIDUAL f�PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY Q STATE AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR O -1IF INDIAN 1101 TANKS AT SITE I E.P.A. L D.#fcptk"l) <br /> RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY WNTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> rs s- 20 �ia4Afom aoq- S jr*' <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME1 CARE OF ADDRESS INFORMATION <br /> AN'aA�r <br /> MAILI GOR STR TAODRESS ✓ bm bintlkale <br /> -1 INDIVIDUAL (] LOCAL AGENCY STATE-AGENCY <br /> P vt Sox CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP DE2_ <br /> PHONE#WITH AREA CODE <br /> C �q ¢ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> os <br /> MAILING OR STREET ADDRESS box bilbiral# 0 INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP O COUNrY.AGENCY 0 FWEML-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -I Q Z 1 2_1 Z 1 ra <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Q II.or III.Q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLOANTSTITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACIL"# <br /> GsAJTR Il <br /> LOCATION CODE -OPTIONAL US TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -CPT/ONAL <br /> Of CENS23. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(9 W) FOROCd1A-A2 <br />