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}'- �'. STATEOFCAUFORMA J <br /> 6`'1 STATE WATER RESOURCES CONTROL BOARD Io <br /> N D UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITYISRE <br /> MARK ONLY 1 NEW PERMIT E:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 RMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 0 A AMENDED PERMIT Q a TEMPORARY SITE CLOSURE <br /> 1. FACIL ITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY E NAME OF OPERATOR <br /> -TO-DRESS NEARESTCROSSSTA ARC (OPTIONAL) <br /> o CtiAirfer W - 7o-a2-G <br /> CITY NAME STATE P CODE NE#WITH AREA CODE <br /> C <br /> ✓ BOX <br /> TO INDICATE O CORPORA 0 anNDUAL O PARTNERS14P 0 DISTRICTS <br /> SIC NTY NCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> NPE OF BUSINESS O tGAS STATIO a 2 DISTRIBUTOR 0 IF INDIAN TANKS IT E.P.A L D.#(op(A..W) <br /> 0 3 FARM & PROCESSOR 0 5 OTHER OR RE, ATION <br /> EMERGENCY CONTACT PER N (PRIMARY) EMER NCY PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST). NE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> Z — — <br /> 1 <br /> NIGHTS: N ME(LAST,FIRST) P #WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> oraoPa SsoCia- S Eta <br /> MAILING OR STREET ADDRESS /J ✓ box mvIk*A 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> //So CORPORATION 0 PARTNERSNP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> oc Q,->' CA4 5 <br /> 11I. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS la*binOkw 0 INDIVIDUAL D LOCAL-AGENCY 0 STATE.AGENCY <br /> 0 CORPORATION 0 PARTNERswp 0 COUNTY-AGENCY D 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 4 4 -[_F_F_EE_E1 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will b 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 aILLIN : 1.D II.O III,O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMIrOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# F ILITY# <br /> ® UMP71 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUNISOR-DISTRICT CODE .OPTIONAL <br /> 23'alo zS 3&& Ch( <br /> T IS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE SRE INFORMATION ONLY. <br /> FOR A(eAo) FOR0033A RR22 <br />