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i <br /> a < <br /> STATE OF CALIFORNIA �5 <br /> STATE WATER RESOURCES CONTROL BOARD 'E o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYSRE <br /> MARK ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMAN SITE <br /> ONE REM O 2 INTERIM PERMIT [] 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME I C NAME OF OP RATOR <br /> ADD SS_ v NE EST CROSS STREET PARCELA(WI L) <br /> tMG <br /> CITY NAME <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> BOX iz CA <br /> T NDICATE D INDIVIDUAL PARTNERSHP (]LOCAL-AGENCY O CDUNTY-AGENCY O STATE-AGENCY E] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS10 ) GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. L D.#(opfbW) <br /> RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CO CT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• UST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ buxbkdW = INDIVIDUAL ED LOCAL-AGENCY (1 STATE.AGENCY <br /> CORPORATION = PARTMFRSIIIP (]COUNTYAGENCY (1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPL D <br /> NAMEOFOWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bo>WWDM = INDIVIWAL O LOCAL-AGENCY STATE-AGENCY <br /> f�CORPORATION = PARTNERSHIP COUNTYAGENCY FEDERAN-AGENCY <br /> CITY NAME STATE ZIP COOS PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBE •Call(916)739.2582 if questions arise. <br /> TY(TK) HQF4 4 -I <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billi 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.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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# ���[FACILITY <br /> AACILITY# <br /> �-I-J "16 14 1 <br /> LOCATION C012E -OPTIONAL CEN0,19,171ACTIF TJWAk SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOWAAED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> PO fXR 1 FCROItl]ARt A <br /> l..• y1 <br />