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STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD `••6 �`+ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A W <br /> ... <br /> COMPLETE THIS FORM FOR EACH F ILrTY/SITE • �" ^"" <br /> MARK ONLY O t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O �PERMANENTLY RE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PE <br /> O a TEM: SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION.&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> D Q1�4q4t NAME OF OPERATOR <br /> A RESS <br /> 6p�l�� /l4 NEAREST CROSS STREET PARCELs(OPfpNAU J� <br /> CITY NAME �(� OZ, —/70—ZV—0 <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA Zat� 33�/-62Ga <br /> Box <br /> TOINDCATE O CORPORATION Q INDIVIDUAL 0 PARTNERSHIP LDG1L-AGENCY COUNTY,AGENCY (] STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTSTYPE OF BUSINESS GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN ;1 OF TANKS AT SITE E.P.A. I.D.s(tplAavyl <br /> 3 FARM Q q PROCESSOR Q S OTHER OOq TRUSRRESEVLANDS 0 <br /> EMERGENCY SONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME( T,FIRST) PH E;W2 <br /> A A DE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA ECODEgoL <br /> TIRT) PHONE#WITHAREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WI7 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ESS f)AIaI ✓ bx b lndib 1 INDIVIDUAL =1 LOCAL-AGENCY O STATE-AGENCY <br /> �L/ V� �CORPORATION � PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PONE a WITH AREA <br /> G L - Z�O <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> U <br /> MAILINGORSTREET ADDRE bot bIR AIS INDIwOUAI Q LOCAL-AGENCY E]STATE-AGENCY <br /> O CORPORATION = PARTNERSMP Q COUKrYAWNCY FEDERALAGENCY <br /> Crrf NAME STATE ZIP CODE P ONE s WITH AREA DE <br /> o G� Z,: -6Zob <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - C) <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.O U.O III.O <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) APPLICANTS TITLE DATE MONTH/DAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY a <br /> �2 1 P -*'50j tj� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> T. ff Z7 �� <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 /> FORMA-R2 <br /> FORM A(990) fry <br />