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�ftw <br /> `-Of zzou.ce <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; 'o <br /> DER ROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> i <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE °•".°'"� <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I, FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS - NEARESTCROSSSTFI PMCEU(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA 17520-ir <br /> BOX CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY p COUNTY-AGENCY STATE-AGENCY lx0lp FEDERAL-AGENCv <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR RESERVATION #OF TANKS AT SITE E.P.A. L D.*(opAmQ <br /> p 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#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME ILAST,FIRST) PHONE:(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 /> MAILING OR STREET ADDRESS ✓ box b Index, p INDIVIDUAL p LOCAL AGENCY p STATE-AGENCY <br /> p CORPORATION p PARTNERSHIP p COUNTY-AGEN;Y p FEDERA#GEN:Y <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAMEOF OWNER CARE OF ADDRESS INFORMAT10 <br /> Q f f�. S <br /> MAILING OR STREET ADDRESS ✓ Ifmdbb# p INDIVIDUAL p LOCAL AGENCY p STATE-AGENCY <br /> P0, os p CORPORATION p PARTNERSHIP p COUNTYAGENCY p FEDERALAGEN;Y <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 F4-F4]-� <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: I.a II.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL ICANTS NAM E IF R INTED B SIGNATU RE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION M FACILITY# <br /> gnoccgo <br /> LOCATION CODE -OPTIONALTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> CENSUS <br /> -3. .2 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 A(9.90) \ FONaW�0.A2 ll� <br />