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agaun ca <br /> STATE OF CALIFORNIA `s <br /> STATE WATER RESOURCES CONTROL BOARD '¢ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� ne <br /> CjCOMPLETE THIS FORM FOR EACH FACILTTYISITE o °a�.°..��. <br /> MARK ONLY F__1 i NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAMW OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTgNAU <br /> 3 AJ Y osn 3- Z.- <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> DiJ CA ,Z06- z - z-BOX <br /> 3>3J <br /> TO INDICATE O CORPORATION (]INDIVIDUAL L__1 PARTNERSHIP LOCAL AGENCY COUKrY#GENCY 0 STATE-AGENCY Q FEDERAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. L D.#(q,*nat) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR v <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(U T.FIRST) 46C PHO2QT #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> P <br /> z-3 31 <br /> NIGHT NWAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREACCDE 71 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDEBS INFOfl ON <br /> MMKK /r C L <br /> f <br /> MAILING OR STREET ADDRESS %eba Iohw W I DUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> 600 =CORPORATION 0 PARTNERSHIP [=)COUNTY-AGENCY C] FEDERAL-AGENCY <br /> CI NAME <br /> STATE# ZIP CODE PHONE#WITH AREA CODE <br /> « C z1 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 'n <br /> MAILING OR STREET ADDRESS box bhgbNe INDIVIDUAL O IDCA4AGENCY STATEAGENCY <br /> (�CORPORATION O PARTNERSHIP COUNTYAGENCY (] FEDERAL-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) HO F4-F4]-� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or IN's checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O IL O III. <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 /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATgN DE -OPTIONAL CENSUS TRACT# -OPT' AL SUPVISOR-DISTRICT CODE-OPTTONAC <br /> 23_F� 32 F <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(9.90) FORM3A R2 (,f- <br />