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soon <br /> L STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD �� o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> r � • o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Q 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER LV CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT � 4 AMENDED PERMIT 0 a TEMPORARY SITE CLOSURE �� <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA_QR FACILITY NAME <br /> NAME OF OPERATOR <br /> doe <br /> O f/.PESio�/E <br /> ADDRESS <br /> OD�• s NEAREST CROSS STREET PARCEL#(OPfIONAU <br /> 55.4 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S?oa / OA <br /> TOINDCATE O CORPORATION O INDIVIDUAL L-1 PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY (]STATE.AGENCY D FFDERALAGENCY <br /> DISTRICTSTYPE OF BUSINESS O ) GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(cpNArMq <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION 2 <br /> O O OR TRUST LANDS �J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: M (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 9Z7- Z) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LA3T.FIR3T) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> A!4v/6tt �_ J asi <br /> MAILING OR STREETADDRESS ✓boa b Mdbau = INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> ZI 7 Z CT S. O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 5 /L4 e,- 2 <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> -OA✓140 S I-AOs# <br /> MAILING OR STREET ADDRESS' M /J/�/J/, �a� I,C box bi^dpab D INDIVIDUAL O LOCALAGENCY STATE-AGENCY <br /> 417v7 5• dl:� IW /��1`r!L/VKI(�,( =CORPORATION ED PARTNERSHIP [-D COUNTYAGENCY FEDERAL-AGENCY <br /> CIS NAME STATE _ ZIP CODE PHONE#WITH AREA CODE <br /> 50 �— 45 0'2-.Z <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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1,O IL NIL 0 <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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN-Y# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ���/,�' <br /> 0 23. <br /> t11HIS <br /> FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 7, <br /> FORMAR2 <br />