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STATE OF CAUFORMA `i <br /> STATE WATER RESOURCES CONTROL BOARD iy <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITYfSITE ��°"���"�� ye <br /> C < A <br /> MARK ONLY Q t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q d AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> 3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Loi Roctie, Lours oeAct <br /> ADDRESS NEAREST CROSS STREET PARCELs(OPTIONAL) <br /> 63o E F, 7, m C 4' 16 -114 ,o -q <br /> CITY NAME STATE ZIP CODE SffE PHONEi WffH AREA CODE <br /> 5-ock ca 45�0� mar y6� -g o <br /> V BOX <br /> TOINDICATE O CORPORATION 0 INDIVIDUAL Q PARTNERSMP LOCAL-AGENCY Q CDUNTVAGENCY 0 STATE-AGENCY O FEDERAL-AGENCY <br /> OBTAICTS <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR - 0 ✓ IF INDIAN s OF TANKS AT SITE E.P.A. L D.a(oprbW) <br /> RESERVATION <br /> Q 3 FARM Q s PROCESSOR ® 5 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE OAVS:NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> r <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boxb WkN. Q INDIVIDUAL Q LOCK-AGENCY I1 STATE AGENCY <br /> O CORPORATION =PARTNERSHIP Q COUNTYAGENCY 0 FEDEI ALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS but'Wik =1 INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP =COUNTYAGENCY FEDERALAGENCY <br /> CITY NAME - STATE ZIP CODE PHONE a 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 -LL_l I T—T—] <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: LD II.O In.O <br /> T141S 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 TIRE OATS MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY• JURISDICTION 0 FACILITY x <br /> mI I IDLIS-11 11 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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(9A0) FOROMA.R2 <br />