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\/ STATE OFCALIFORNIA •`s <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a <br /> °.�,.o.a,.. <br /> COMPLETE THIS FORM FOR EAC ACILITYISRE <br /> MARK ONLY F_­11 t NEW PERMIT 0 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SRE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF CILITY NAME NAME OF OPERATOR <br /> G <br /> ADDR S NEAREST CROSS STREET PARCEL#(OPTIONAQ <br /> 1 <br /> CITY NAMESTATE ZIP E SITE PHONE 0 WITH AREA CODE <br /> cA Cf $3 <br /> ✓ BOX <br /> TOINDICATE O CORPORATION D INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O FARM 4 PROCESSOR GAS STATION 0 2 DISTRIBUTOR 0 -/ IF INDIAN #OF TANKS AT SITE E.P.A. L D.0(apftW) <br /> 3 5 OTHER RESERVATION <br /> O O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DA ' NAME LA51,FIRS ^ PHONE 1^TH AREA CODEDAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> [ne <br /> 44 <br /> NIGHTS: NAME(LAS IRST) / COlJ' PHONE 8 WITH A EA C/DDE 7 <br /> 16 <br /> , NIGHTS: NAME(LAST,FIRST) PHONE-8 WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME , CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bw b Irdbab INDIVIDUAL = LOCAL-AGENCY D STATE-AGENCY <br /> 15 • []CORPORATION PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P ONE#WiTtl AREA <br /> C 42 <br /> 74 <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bDxbhWVO 0INDIVIDUAL 0 LOCAL AGENCY STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO 4 4 -� <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. II.O III.0 <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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACIL L, <br /> LOCATN)NCODE -OPTIONAL CENSUST ,,T0 OPTIONAL SUPVISOR-DISTRICT CODE -OPTgAIAL <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) FORD033AA2 1 <br /> \V/1V' vlv � ✓ ✓71 <br />