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STATE OF CALIFORNIA ° <br /> STATE WATER RESOURCES CONTROL BOARD -•,•. °i' <br /> ERGROUND STORAGE TANK PERMIT APPLICATION - FORM A m v a <br /> 0 <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITE <br /> MARK ONLY U 1 NEW PERMIT D RENEWAL PERMIT E 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q A AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITYNAME / NAME OF OPERATOR <br /> G( SiJh <br /> ADDRESS NEAREST CROSS STREET P c <br /> CITY NAME 5 U A'O !.� <br /> STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> I/ BOX S4—vcl,- 4ro ( CA `TS�q <br /> TO INDICATE Q CORPORATION Q IWIVIWAL Q PARTNERSNP Q LOCAL-AGENCY <br /> DISTRICTS COUNrY.1GEN;Y Q STATE-AGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESS Q I GAS STATION a 2 OISTR18UTOR ✓ IF INDIAN s OF TANKS AT SITE E.P.A. L 0.A(opranaQ <br /> Q ] FARMG ATION <br /> d PROCESSOR O 5 OTHER �OR RRUSTVLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA COOS NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ W.bYNEaM Q INDIVIDUAL Q LOCAL-AGENCY <br /> Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHP IQ COUNrY-AGENCY Q FEDERAL.AGEN:Y <br /> CIN NAME STATE ZIP COOS I PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME Of OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ WX0wd m Q INDIVIDUAL Q LOCAL AGENCY <br /> Q CORPORATION Q FEGERASTATE-AGFNCY <br /> Q PAgTNERSNP Q COUNTY.IGENLY Q FEDEPAL#GEN;Y <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)739-2582 if questions arise. <br /> TY(TK) HQ 4 F4 - p 3 d (o <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 SILLNG: I.U it.[::] 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 A SIGNATURE) AP PLICANrS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY a &OL(- 'S <br /> ) ` Y 4 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR.DISTRICT CODE .OPTIONAL <br /> 0 / 1 Z3Xb 1y 9z- L,;b <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(9-901 /'/.. FOROalUA2� <br />