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eosoue e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C,""___�NDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> ,.o.e,. <br /> COMPLETE THIS FORM FOR EACH FACILRYISRE <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT D S CHANGE OF INFORMATION O 7 PERMANE LY OSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE - <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS 'OleNEAREST CROSS STREET PARCELA(OPTOMU <br /> 7a-'F C .YA r <br /> CITY NAME STATE ZIP CODE SITE PHONEY WITH AREA CODE <br /> CA <br /> TOINDICATE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LDCAL-AGENCY 0 COUNTY-AGENCY STATE AGENCY (] FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 i GAS STATION Q 2 DISTRIBUTOR0 ✓ IF INDIAN •OF TANKS AT SITE E.P.A. L D.*(WAMW) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR a OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> F�cl C l un- C4' <br /> MAILING OR STREET ADDRESS ✓ bol b Ndmie 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 3.5-';E AW CORPORATION 0 PARTNERSHIP 0 COUNrYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> NCA w C+ 9Yss6 <br /> III. TANK OWNER INFORMATION- UST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS V, 119abIrKitza = INDIVIDUAL D LOCAL AGENCY O STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY O 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 - 0 3 a (a <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is cher <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: E 0 II. III.E <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# rjEYON 1,Z, <br /> LOCATIONCODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DIS ICT CODE -OPTIONAL <br /> n/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,U ATNGE OF SITE INFORMATION ONLY. <br /> FORA R2 <br /> FORM A(9-90) <br />