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STATE OFCALIFORWA sous ea`�, <br /> STATE WATER RESOURCES CONTROL BOARD ... � g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :� �e <br /> COMPLETE THIS FORM FOR EACH F LITYISITE `.4.pn��N�� <br /> MARK ONLY O i NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SIE <br /> ONE REM F--1 2 INTERIM PERMIT 4 AMENDED PERMIT 0 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> R�9TAV 3573 <br /> DDR SS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> d N sq— 1Ds4 <br /> CITY NAME STATE 21P CODE SITE PHONE#WITH AREA CODE <br /> �'c�lbcl ca �T 520 <br /> ✓ BOX <br /> TOINDICATE CORPORATIONINDIVIDUAL O PARTNERSHIP E:1 LOCAL-AGENCY E--1 COUNTYAGENCY E-1 srATE.AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O ) GAS STATION Q 2 DISTRIBUTORO '/RESERRESERVATION <br /> INDIAN #OF TANKS AT SITE E.P.A. I.D.#(apa"W) <br /> 3 Q 3 FARM 4 PROCESSOR �5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 4.�1u, ZL3 GZ7-7o[b <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 44V(/J S- GtWA�a `TiduS`T <br /> MAILING OR STREET ADDRESS d� n,/� ✓ boa binkats D INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> A17 S. 44"'n 1/�� YAI VE =CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITYNAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 5 c c crSBaL <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> mvl4 5_ 4v465eA!) --rjQL9!5'1 <br /> MAI;4G�O OR STREET ADDRESS boa bir&,M INDIVIOVAL LOCAL STATE-AGENCY <br /> � /T/�� j• ,� 0�LL LVE =CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY AME 8TATE ZIP CO <br /> 4q AJ$ZL PHONE#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 -LTJ <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II' checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O 11. III.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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® akr�u <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-CIS TRICT CODE -OPTIONAL <br /> o z�. � 1 32- &r <br /> y <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 /> FORM A(&eD) FOR0033A R2 <br />