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e�caun es <br /> STATE OF CALIFORNIA .r ct <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "� �e <br /> e4,ro�N`e <br /> COMPLETE THIS FORM FOR EACH FACILITYBRE <br /> MARK ONLY 0 T NEW PERMIT O 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT M 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE 5v <br /> I. FACILITY/SITE INFORMATION-/&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF ILI oAME oNs rooluc4S NAMEOF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL$(OPTIONAL) <br /> CITY NAMEdf STATEZIP CODE THAREACODE <br /> CA <br /> BOX <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY O COUNTYAGENCY Q STATE-AGENCY (] FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O ) GAS STATION 0 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(apIima) <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR Q 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> GAYS: NAME(LAST,FIRST) PHONE a/WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE%WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- UST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b Nd"W = INDIVIDUAL l- LOCAL-AGENCY =STATE-AGENCY <br /> O CORPORATION ED PARTNERSHIP =COUNrYAGENCY = FEDERAL-AGENCY <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 V bm biW1CM INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION PARTNERSHIP Q COUNTYAGENCY O FEOERALAGEHCY <br /> CITY NAME STATE ZIP OODE PHONE#WITH AREA OODE <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 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.a II.Q 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CIOOUNNTTYY1# "�'"-T JURISDICTION# FACILITY# <br /> M ge06'e 2 yI I I I IZ Fv <br /> LOCATK)N CODE -OP77ONAL CENSUS TjUCZ#-OPTIO(JAL SUPVISOR-DIST ITCODE -OPTIONAL /'I n/ <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(&W) FORMU R2 <br />