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eso�- es <br /> v STATE OFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACk- <br /> uo <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITE <br /> MARK ONLY Q I NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION Yf 7 PERMANEN CLO <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT ED a TEMPORARY SITE CLOSURE �D <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) VV <br /> DBAO FACILITY NAME NAME OF OPERATOR <br /> ZX <br /> ADD S • ( NEA CROSS STREET PARCEL#(OPFDNAL)YI <br /> r pa <br /> Cltt E STATE F SITE PHONE S WITH AREA DOGE <br /> CA <br /> BOX <br /> TOINCICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS F-1 , GAS STATION 0 2 DISTRIBUTOR O R SV IF INDIAN <br /> ERVATION IN OF T AT SITE E.P.A. I.D.#(aprw�a) <br /> 0 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: ME(LAST,FIRS _PHONE a WIT AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE OITHAREA CODES NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I I t-1 <br /> II. PROPE OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS I ORMATION <br /> MAILING OR STREET DRESS ✓ bubindkWe INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 rNERSHIP O COUNTY-AGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bwbindi:M O INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP ACOUNTYAGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE I plNE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST OORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 44 -1 1 1 1 1 1 -1 <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: L 11. 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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 151 / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -9PTIONAL <br /> OO ty <br /> / <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 /> FORMA(9.90) FOROW3A <br /> NW.0 <br />