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coon e <br /> STATE OF CALIFORNIA i eO. <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD 3 tl�, v o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> 4'.. o <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �����`•- <br /> MARK ONLY F--] I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE i✓ <br /> I. FACILITY/SITE INFO UST BE COMPLETED) <br /> DSA OR FACILITY NAME OF OPERATO <br /> N AREST CROSS STREET PMCELaIOPfpU <br /> NA <br /> Go J STAT`EA ZIP CODE �O TE PHONE*W H 2- <br /> A CODE <br /> Tf7INDICATE CORPORATION IND] TNERSHIP 0 LOCAL-AGENCY 91�COUNTY-AGENCY STATE-AGENCY (] FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR O R SERVATION j*OF TANKS AT SITE E.P.A. I.D.8(oplanW) <br /> O 3 FARM 0 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(UST,FIRST) PIJONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> 333- 2741 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME TCARE OF ADDRESS INFORMATION <br /> 9; J'7/� <br /> MAILING OR STREET ADDRESS �/ ✓ Oo[blMkaM OINDIVIDUAL OLOCAL-AGENCY 0STATE-AGENCY <br /> JAl—,:-5 CORPORATION PARTNERSHIP COUNTY-AGENCY = FEDEMLAGENCY <br /> CV NAME STATE� ZI e PHONEi WITH AREA CODE <br /> Ill. ITANK OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME OF OWNERC ARE OF ADDRESS INFORMATION <br /> � <br /> MAILING 9R STREET ADDRESS /� ^ /�. W-bbd"W INDIVIDUAL OLOCAL-AGENCY OSTATE-AGENCY <br /> I16! POAe.� ��L A A--I"•- O CORPORATION PARTNERSHIP 0 COUNTYAGENCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Go D2 �i2�v <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -FT—FT—FT7 <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.DC II.O III.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 IITED a SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYPIEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Al FACILITY• �H�1�'/1 gv <br /> 2z <br /> LOCATION CODE -OPTIONAL JOE 3. �S/U{�JISoOR-DISTRICT CODE -OPTIONAL 'fOZ L/Y <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) FOR0033A-F2 <br />