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v <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD '°`°-• .f <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O T NEW PERMIT a O RENEWAL PERMIT cy 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q A AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE 53 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITYNAME NAME 9F OPERATOR <br /> L//hl ROW <br /> lin /r <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAL) <br /> 2-2 8.2 Al, ClepyvAik aw Rr <br /> CITY NAME STATE ZIP COOE SITE PHONE#WITH AREA CODE <br /> C'/ewl ^, CA 952Zr7 .209- 75Sts'E$3 <br /> T 10 NDICATE O CORPORATION p INDIVDUAL Q PA TNERSHP O LOCAL-AGENCY O COUNTY-AGENCY p STATE-AGENCY <br /> DISTRICTS FEDERAL-AGENCY <br /> TYPE OF BUSINESS 0 t GAS STATION Q 2 DISTRIBUTOR - Q ✓ IF INDIAN is OF TANKS AT SITEE.P.A L D./(apr1&W) <br /> RESERVATION <br /> 0 7 FARM O & PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)( Y)•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#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> JIM o 1 or <br /> MAILING OR§TREET ADDRESS ✓ bNObau INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> , 0. ac'v- CORPORATION PARTNERSHIP COUNTY,AWWY E:] FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> C�L'Vv� N� CA s�2 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Sa c cts <br /> MAILING OR STREET ADDRESS ✓ InabVWiCM Q INDIVIDUAL ED LOCAL AGENCY Q STATE-AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE LP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-M4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 LZ I"-F--1 <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 TIRE DATE MONTFVDAYNFAR <br /> LOCAL AGENCY USE ONLY ��AA N 0,93 —0q0 <br /> CODUNTY# JURISDICTIONN IL 6 <br /> E� I '113 <br /> 2 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT*-CP7pNAt SUPVISOR-DISTRICT CODE -OPTpNAL <br /> --41111111110 1:1 ?3 - 2 3;7,c> C <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) FIXiOW3AR2 fA <br />