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STATE OF CALIFORNIA � .- o <br /> l.� STATE WATER RESOURCES CONTROL BOARD 3ya� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ,.:; o <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION 81 ADDRESS-(MUST BE COMPLETED) <br /> DBA/QTR FACILITY NAME g1 NAMEOFOPERATOR <br /> /� l ��S G • <br /> ADDRPARCEL/(OPTIONAL) <br /> ESS NEAREST CROSS STREET <br /> l0 N �! <br /> CITU NAME STATE q�G <br /> 2( CODE SITE PHONE#WIT <br /> H ggREA LADE <br /> CA q Zo�tJ —FsSur <br /> ✓ Box -AGENCY <br /> INDIVIDUAL (]PARTNERSHIP O LOCAL-AGENCY COUNfVAGENCY - STATE-AGENCY FEDERAL-AGENCY <br /> INDICATE DISTRICTS <br /> TYPE OF BUSINESS L GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN T AT SrrE E.P.A. I.D.#(OPIkON) <br /> Q RESERVATION //,� <br /> O 3 FARM 4 PROCESSOR ��5 OTHER OR TRUST LANDS y <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYSSyNAMF(LAST.FIRST) .. PHON READS OO DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTSNNNAME(LAST.FIRST) PH ONE a W1IHH AREAC5fE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE <br /> 1 Z ' � <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> _r—"g <br /> MAILING,014 ADDRESS ✓ boab kaV D INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> /Q. BOX l �, CORPORAPON PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITU NAME I STATE ZIP;CODE PHONE a WITH AREA CODE <br /> S L"T�IC/ C ;7 t fiori) c1�!6—S ;oo <br /> III. TANK OWNER INFORMATION- UST BE COMPLETED) <br /> NAMEOFOWNER CARE <br /> ,OFA RESS INFORMATION <br /> r <br /> MAILING OR STREET ADDRESS INI'bMkab D INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> vE 0 CORPORATION PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA 90DE <br /> s✓LA4uen! Cw 1 T65-5- (Zo-1) <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739.2582 if questions arise. <br /> TY(TK) HQ 4 4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the k owner unless box f or II's checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY K PLEDGE,IS TRUEAND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTH/DAV R <br /> LOCAL AGENCY USE ONLY <br /> COUNrPY# JURISDICTION# � FACILITY# <br /> � �1LIi �-Irw./r0 <br /> SUPVISOR-DISTRICT CODE -OPTK <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL IAML <br /> 32 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF srTE INFORMATION ONLY. <br /> FORDXIMA2 \ <br /> FORM A(9-90) 67 /A <br />