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STATE OF CAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD °o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> v; <br /> ef— I— COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY L—.i I NEW PERMIT 0 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLO D SRE <br /> ONE ITEM O 2 INTERIM PERMIT 0 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 /> O <br /> ADDRESS NEAREST CROSS STPIIE11T PARCELS(OPTIONAL) <br /> t/ 27 r , .44L 10 -210-o - <br /> CITYNAME STATE ZIP CODE SITE PHONE S WITH AREA CODE <br /> S c CA <br /> BOX <br /> TO INDICATE O CORPORATION D INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY D FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR 0 ✓ IF INDIAN IS OF TANKS AT SITE E.P.A. L D.t(°PUDW) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR [--] 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS' NAME(LAST,FIRST) PHONE S WITH AREACODEp DAYS: NAME(LAST,FIRST) PHONE F WITH AREA CODE <br /> E o - 1 - 90 <br /> IC : NAME(LAST,FIRST) 9E o WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME _ CARE OF 6DD ESSINFO TIOy�O� <br /> S / la k n L A5-110 /l7 <br /> MAILING OR STREET ADD Be /� ✓toxbRNICW INDIVIDUAL =LOCAL-ADENCY EENCY <br /> STATE-AG <br /> Q ODG go 170 O CORPORATION = PARTNERSHIP =COUNTY-AGENCY [::] FEDERAL-AGENCY <br /> CITY NAME STAATTAR <br /> E ZIP CODE PHONE a WITH EA CODE <br /> Q— ..� L. J�d 30 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET APDRESS Oov bintlicaN D INDIVIDUAL 0 LOCALAMNCY STATE-AGENCY <br /> O Aqrd CORPORATION O PARTNERSHIP 0 COUNTYAGENCY E:j FEDERAL-AGENCY <br /> CITY STATE I ZIP CODE PHONE S WITH AREA CODE <br /> O <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO 4 4 -1 1 FT= <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: 1.0 IL vIII.❑ <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 TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY• JURISDICTION 1 FACILITY 1 <br /> LOCATK)NCODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT OODE -OP770NAL <br /> w23_ s- <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 A19-90) FORNR]AA2 \ <br /> -�� *two - a <br />