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pec unc�e <br /> STATEOFCALIFORNIA �s <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O t lam' PERMIT Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT � 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS /� NEAREST CRO REET PARCEL#(OPTIONAL) <br /> 20 , CA <br /> CIT/NAME STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> CA 2oS <br /> TO NDIICCATE O CORPORATION a INDIVIDUAL o PARTNERSHIP E::]LOCALAGENCY O COUNTY#GENCY 0 STATE.AGENCY o FEDERAL#OENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN is OF TANKS AT SITE E.P.A I.D.4(OpIkv W) <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CADS <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓barblrmkA = INDIVIDUAL ED LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION = PARTNERSHIP COUNTY AGENCY Q FEOERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE*WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ W.bmbaN 0IWNIDUAL LOCAL-AGENCY 0 STATE AGENCY <br /> CORPORATION = PARTNERSHIP Q CWNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i 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 -� <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.UK II.[= III.O <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 a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUrnNTY# JURISDICTION III FACILITY• <br /> L I1 ® GLAgk2o <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 23, Ss� i <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(9-90) FOR999IATi2 \ <br />