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't60JR � <br /> STATE OFCALIFORMA "' <br /> STATE WATER RESOURCES CONTROL BOARD s` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> l� COMPLETE THIS FORM FOR EAC ACILITY51TE ����"RJ <br /> MARK ONLY Q L NEW PERMIT O 3 RENEWAL PERMIT S CHANGE OF INFORMATION O 7 PERMANENTLY CL <br /> ONE ITEM Q2 INTERIM PERMIT [7 4 AMENDED PERMR ❑ e TEMPORARY SITE CLOSURE5J 3 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY N NAME OF OPERATOR <br /> AD S NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 4 <br /> CITY NAE STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> BOX <br /> TO INDICATE E-1 CO; TION INDIVIDUAL I_1 PARTNERSHIP D LOCAL-AGENCY O COUNTYAGENCY (] SrATE.AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS T OAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN is OF TANKS AT SITE E.P.A I.D.#(optkn4) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> F <br /> YS: NAME(LAST,FIRST) PHO •WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> HTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST B COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ but lydk Q INDIVIDUAL O LOCAL-AGENCY Q STATE AGENCY <br /> D CORPORATION PNRNERSMP COUNTYAGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAM OF OWNER C CAREOF ADDRESS INFORMATION <br /> S <br /> MAILING OR STREET ADDRESSf Wxbhtl� INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 4 O CORPORATION D PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CRY NAME n TATE ZIP DE PHONE 0 W TH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMB /L-�JCall(916)739.2582 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and bi . g 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 D BILLING: L O IL 0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE B T OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTHIOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> SUPVI507RICT CODE -OPTIONAL <br /> LOCATnIODE -OPTIOARL CENSUS TRACT# -OPTIONAL <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 /> �� <br /> FORM A(9 90) FORW03A R2 <br /> 5-I ?- g � <br />