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•ggOUR � <br /> STATEOFCAUFOWSA <br /> STATE WATER RESOURCES CONTROL BOARD ;a� ,Ae'> <br /> C UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A � �° <br /> a i.. o <br /> C-4.ORNJ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1 I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [-] 7 PERMANENTLY CLQMQ.grrE <br /> ONE REM [—] 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 5 TEMPORARY SITE CLOSURE aD <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAFACILITY NAME N OF OPERAT fl <br /> A U OOaS ,ZA(0, Ex E EN BAU4N <br /> ADDRE�S� D 5 NEAREST10CmRL.00 ROSS STREETPARC/#(/� _ 06Z <br /> CITY NAME STATE ZIP CODE SITE PHONE41RCODE <br /> 5TO( KDV ca v_958 O <br /> ✓ BOA <br /> TO INDICATE CORPOMTIGN 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY 0 COUNTYAGENCY O STATE AGENCY D FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O i GAS STATION 0 2 DISTRIBUTOR / <br /> RESERVATION <br /> IF INDDION #OFF S AT SITE E.P.A. L D.#(cPIkvW) <br /> 0 3 FARM 0 4 PROCESSOR ,L�C/J� 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•options] <br /> D YS: NAME(LASTFIRST) ^ � HONE#WITH AREA ODE DAYS: NAME(LAST.FIRST( PHONE#WITH AREA CODE <br /> r6FNAAMMMEE(((LL , <br /> NIGHTS: AST,FIRST) /,(/ PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME,') CARE <br /> ��^ CARE OF ADDRESS INFORMATION <br /> MAI F ORO STREET sQDRESS /2 O ✓7 INDIVIDUAL 0 LOCAL.AGENCY I1 STATE-AGENCY <br /> /V/ox CORPORATION 0 PARTNERSHIP �COUNrYAGENCY = FEDEMLAGENCY <br /> CITY�� STtiA ZIP DE D M HONE#WIT H AREjC9s8 d <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) (( YG✓ LV[ !/JJ/tel 6 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Prat ►J qe.. <br /> MAILING OR STREET ADDRESS bmblrda INDIVIDUAL D LOCAL AGENCY Q STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP D COUNTYAGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ4 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 hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O 11.IV 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 B SIGNATURE) APPLICANTS TITLE DATE MONTHDDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> L.>1-L�N JURISDICTION <br /> s FACILITY 9 AC7qF0 <br /> L00 /N CODE -OPTIONAL CENSUS TRACT#_-OP OPTIONAL SUPVISOR-i /1DISTRI:T CODE -OPTIONAL / <br /> pv <br /> THIS FORM MUST BE A PA A7 LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(9-90)1,,� <br /> \ FOR00]7AR2 �\ <br /> 144.-� .I...' ,, �a\v <br />