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e�oun ea <br /> `i STATE OF CALIFORNIA ../ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A e <br /> COMPLETE THIS FORM FOR EACH FACILTTYISTTE <br /> MARK ONLY D t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FATY NAME NAME OF OPERATOR <br /> ADDRES NEAREST CROSS STREET PARCEL#(OWDNAU <br /> 1 <br /> CITY NAME STATE ZIP CODE SITE PHONE•WITH AREA CODE <br /> CA <br /> T NOICATE I=1 CORPORATION (]INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN 14 OF TANKS AT SITE E.P.A. I.D.0(476m 11 <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bo lDintlkaN Q INDIVIDUAL LOCAL AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box b Adan ED INDIVIDUAL 0 LOCAL-AGENCY Q STATEAGENCY <br /> I�CORPORATION 0 PARTNERSHIP COUNTYAGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE t WITH AREA CODE <br /> IV. BOARD OF EOUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO F4-F4]-� <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: L O II.0 111.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR INTED&S IGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNT/u _ ^_JHRISBICTTOX—# FACILITY g <br /> lu <br /> LOCATION CODE -CPTIOAUL CENSUSTMCTi- TAOAfAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> P_3, <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 /> ORM A(9-90) FOROMA R2 \ <br /> G <br /> '` I'�� <br /> '`1 `/ /� <br />