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STATEOFCAUFORNA i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR!!T FACILITYBITE <br /> MARK ONLY Q I NEW PERMIT 3 RENEWAL PERMITI <br /> 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 a AMENDED PERMIT 0 s TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> �'^ pN <br /> ADDRESS n � NEAREST CRq STREET ®/ELA(OPfpNAU <br /> 3a N A- OGTA/ — A <br /> CITY NAIJE STATEZIP E SITE PHONE#WITH AREA CODE <br /> CA $ <br /> T I DILATE CoRPORATm INDrIll 0 PARTNERSHIP Q LOCAI.AGENCY 0 COUNrY.AGENCY Q STATE-AGENCY D FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN A OF TANKS AT SITE E.P.A L D.A fglXk AU <br /> Q 3 FARM Q A PROCESSOR 0 S RESERVATION <br /> OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: ME(LAST,FIRSnPHONE A WITH AREA CODE <br /> uO4dPl —36 — —5 —6 <br /> NIGHTS: NAME(LAST,FIRST) PH E A WITH EA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> MAXING OR STREET ADORES ✓box I Q INDIVIDUAL E3 LOCAUAGENCY Q STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER / CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> MAILING STR ET OOF biMicaM [:1 INDIVOUAL Q LOCAL-AGENCY O STATE.AGENCY <br /> COflPOHATNNI 0 PARTNERSHIP [:3 COUNrYAGENCY E:1 FEOERAL.LGENCY <br /> CRY NAME STATE LP CODE PHONE A WITH AREA CODE <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 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: 1. II,a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY)VNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED S SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a <br /> LOCATION CODE •OPTIONA CENSUS TRACT OPTIONAL PVISOR-01ST TCODE - <br /> 23 2 2aIlIir, C74 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,uNL�EnTHITWrMTNGE OF SITE INFORMATION ONLY. f <br /> FORMA090) FOR0033AA2 U� <br />