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-��oon es c <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD iy ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "m� y s <br /> �( •,: <br /> C�I,IOn Min <br /> COMPLETE THIS FORM FOR EACH FACILffYISITE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Ey7 PERMANENTLY CLOSED SITE <br /> ONE REM D 2 INTERIM PERMIT F-1 4 AMENDED PERMIT Q 8 TEMPORARY SITE CLOSURE 3-3 <br /> I. FACILITYISITE INFOR/M�AT[IIOWN&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR CILITVN d %i NAME OF OPERATO <br /> ADDR SS NEAREST CROSS STREET PARCEL a(OPTIONAL) <br /> CI E STATE ZIP SITE PHONE a WITH AREA CODE <br /> CA <br /> BOX <br /> T NDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COIINTYAGENCY Q STATE AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION 0 2 DISTRIBUTOR Q '/ IF INDIAN NOF TANI{S AT SITE E.P.A. L D.N(apfbnell <br /> flE3ET ANDS / <br /> ON <br /> 3 FARM 0 4 PROCESSOR 0 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 a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bur bAbkab Q INDIVIDUAL Q LOCALAGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ )OA bindkVa Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP E::)COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ [4F4 -1 -4-461 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O U.O III. <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 a SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY a <br /> 591 eL✓✓bZZ I I I zi�j �,v9 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPPWNAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF ITE INFORMATION ONLY. <br /> FORMA(9-90) <br /> /nJ/T V4 // FOR0033AR2 <br /> �/ <br />