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STATE OFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A 3 e f <br /> MAR <br /> e <br /> o> <br /> COMPLETE THIS FORM FOR EACH FACIUTY/SITE <br /> ONE REM ONLY 1 NEW PERMIT <br /> ❑ 3 RENEWAL PERMIT <br /> ONE ❑ b CHANGE OF INFORMATION [-] 7 pERMANEN7LY <br /> ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT <br /> ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAORFA ILITVNAME NAME OF OPERATOR <br /> er �CS ✓) r CAC <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPNONAL) <br /> 1S (# 8 S. 5 0 ► �o , <br /> CITY NAME STATE ZIP rODk I WE PHONE#WITH AREA CODE <br /> c CA I r7-oq %Z3- 7CO 2- <br /> v BD% <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 DIST I-AGENCY O COUNTY-AGENCY STATE AGENCY FEDEML-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN 10 OF TANKS AT SITE I E.P.A. 1.D.a ftWm ae <br /> ❑ 3 FARM ❑ A PROCESSOR OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAJI.FIRST, PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> r� .Vk� Z3 7`D©Z <br /> NIGHTS: NAME(LAST.FIRS75 PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME /V v � � /� rt�1 _ � CARE OF ADDRESS INFORMATION <br /> MAILING OR^•STREET ADDRESS V✓L- 1� ✓WCbmkm O INDIVIDUAL [=1 LOCAL AGENCY STATE AGENCY <br /> CIA0 0 CORPORATION = PARTNERSHIP = COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY (O STATE- ZIP CODE PHONE a WITH AREA CODE <br /> NAM <br /> c (C)A C/ 532v - ZY S <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORES bo�bMkw f�INDIVIDUAL Q LOCM-AGENCY 0 STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP =COUNTY-AGENCY (] FFDERAL-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) HQ K41- <br /> V. <br /> 4 -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.❑ 11.Q III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY GF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTSTITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY IIf <br /> �NTY# JURISDICTION# FACILITY# Eck It^_15 <br /> K S 6 <br /> LOCATIONCODE -OPTIONAL CENSUSTRACTa -OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL 6 a -2- <br /> THIS <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLFORY. <br /> FORM A(9-90) // <br />