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— �soun es <br /> STATEOFCAUFORNA ^. `. <br /> STATE WATER RESOURCES CONTROL BOARD low <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :`� ae <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY 0 I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT = a TEMPORARY SITE CLOSURE <br /> f. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB FACILITY NAM NAM60FOPERATOfl <br /> L rl-q lana r-4Iv, ��Q. 7-,/4 <br /> AjESS NEAREST CROSS STREET PARCEL A(OFnONAU <br /> (s o I hf MII d <br /> Cltt to) <br /> ST TE ZIP <br /> NAM SITE PHONE#WITH AREA CODE <br /> I/ Box <br /> TO INDICATE CORPORATION O INDIVIDUAL = PARTNERSHIP O LOCAUMGENCY Q COUNrYAGENCY O STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 I GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDUW Is OFT AT SITE E.P.A L D.#(tpiow) <br /> RESERVATION 1�..1f/ <br /> Q 3 FARM O 4 PROCESSOR Q S OTHER OR TRUST LANDS <br /> ,', only change <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECON ARY)•opdonal <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) PHONE#NTH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bmoii S O INDIVIDUAL Q LOCAL-AGENCY Q STATE4GENCY <br /> 0 CORPORATION I=PARTNERSHIP O COUNTYAGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ba Ili INN O INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cal((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 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.Q II.[�] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION a FACILITY# <br /> ® gw ii I I I 11ss <br /> LOCATION 000E -OPTIONAL CENSUS TRACT# -OPTIONAL SUPwj-DISTRICT CODE -OPTIONAL <br /> Z3 60 2 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANCE OF SITE INFORMATION ONLY. <br /> FOR003AA2 <br /> FORM A(490) \ <br />