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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACIUTy/SrTE <br /> MARK ONLY Q NEW PERMIT O 3 RENEWAL PERMIT5 CHANGE OF INFORMATIONONE REM 2 INTERIM PEgM1T O T PERMANENTLY CLOSED SITEQ d AMENDED PERMIT O 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> �}• NAMEOFOPERRAATOR <br /> ADDRE�y O ^ O�J �/4 <br /> 7 G���� p JI <br /> NEAR /T PARCELNfOPfpNAy <br /> CITY NAME /T <br /> STACA <br /> L-rb��D TE PHIPNE a WITH AREA CODE <br /> ✓ Box J g6- O/L <br /> TO INDICATE 01 CORPORATION VIDUAL PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY <br /> DISTRICTS L� STATE-AGENCY 0 FEDEMLAGENCY <br /> TYPE OF BUSINESS Q TATXTN O 2 DISTRIBUTOR ✓ IF INDIAN 0OF TANKS AT SITE E.P.A. L D.a(npNmyJ <br /> 3 FARM O d PROCESSOR O 5 OTHER O0 TgUSTVLANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Dptlonal <br /> GAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> B+owi Go.2 36 — D/Z <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �� <br /> MAILING OR ST EE ADDR SS �I L� /� /� ✓ bTbbdka IVOUAL QLOCAL-AGENCY <br /> 7 �+ �� ref FAY L CORPoRAT ON 0 PN TNERSHIP 0 STATE AGENCY <br /> CITY NAME C7 COUNTY-AGENCY I� REDERALAGEWY <br /> STAB� ZIP CODE� � PHONE a WITH AREA CODE <br /> i/)' Gam ' 4 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER <br /> p �D <br /> CARE <br /> M6ASTQREEQ1AAtDoRESS baOFbAiWDicDagNE21—INDIVIDUAL <br /> INDIVIDUAL LOC . STATE-AGENCY <br /> /702 <br /> I1 CORPORATION Lj PARTNERSHIP <br /> D COUNrYAGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE U©T PHONE a WITH AREA CODE <br /> GA- �7 <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 lank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS ANDSILLING: LO II.e <br /> III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND COR ECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTIONS FACILIT <br /> 3 � <br /> LOCATION CODE -CPflONAL CENSUSTRACTa -OPnONAL SUPVISOR-DIS TRICT CODE -OPTIONAL <br /> .2Z <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) FO/RRM3A^R22 <br />