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ryoJ• <br /> v STATE OFCAUPORNIA r•� �*� <br /> STATE WATER RESOURCES CONTROL BOARD i ° <br /> DERGROUND STORAGE TANK PERMIT APPLICATION- FORM A "®� U° <br /> C C•(•O Y <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE or <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> s CA <br /> ADDRESS NEAREST CROSS STREET PARCELN(OPTIONAU <br /> 7 E. - Igo -02.-3 <br /> CITY NAME STATE ZIP CODE SITE PHONE S WITH AREA CODE <br /> ,j CA - -71/0(7 <br /> TO pC TE O CORPORATION D INDNIDUAL M PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDEPAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS F7 1 GAS STATION Q 2 DISTRIBUTOR = <br /> ✓ IF INDIAN A OF TANKS AT SITE E.P.A. 1.D.i(oplbnnp <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonil <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST( PHONE At WITH AREA CODE <br /> vJJ A StG - 8= 06 <br /> N HTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME n-� CARE OF ADDRESS INFORMATION <br /> t� S <br /> MAILING OR STREET ADDRESS ✓ bob Ridbals 11 INDIVIDUAL E:] LOCAL-AGENCY E:I STATE-AGENCY <br /> D Ox Aotlg CORPORATION O PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> k C s 201-gW — 71elo& <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> sawe QS S <br /> MAILING OR STREET ADDRESS box binEkw INDIVIDUAL Q LOCAL-AGENCY 0 STATE AGENCY <br /> Q CORPORATION D PARTNERSHIP 0 COUNTY#GENCY 0 FEDERAL-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 F4_F4_1- 3 O <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.0 11.Z III.❑ <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) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Eff s CW_W? <br /> LOCATION CODE -OPTIONAL <br /> CENSUS TRACT i -OPTIONAL <br /> 2 azz 7,3.S0 'r/q/ C <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 /> FOR0933A-R2 <br /> FORM A(9-90) p\ <br /> Y <br />