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STATE OF CALIFORNIASTATEINATER RESOURCES CONTROL BOARD <br /> _ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM A <br /> COMPLETE THIS FORM FOR EACH,TkCILITY/SITE • Y` .ry„ o+o <br /> MARK ONLY ❑ 1 NEW PERMIT Q ] RENEWAL PERMIT a-` • �• <br /> ONE REM 5 CHANGE OF INFORMATION ❑ ) PERMANENZCLO-ffrr�:] <br /> Q 2 INTERIM PERMIT ❑ A AMENDED PER <br /> Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME <br /> / NAME OF OPERATOR _ <br /> AODREa'S 7�G CY7J r, C CC<h �✓�tF s i U <br /> 4vL <br /> NEAREST CROSS STREET I PARCEL/(OPTIONAL) <br /> CITU NAME <br /> STATE ZIP CODE SITE PFIONE s WITH AREA CpOE <br /> oINDICATE aAno <br /> �x E O coR alx T L CA 9 S�o I %- Y6 C•- j 7 <br /> [j INDIVIDUAL Q PARTNERSHIP I]LOCAL-AGENCY Q COUNTYAGENCY <br /> DISTRICTS CI STATEdGENCY Q FEDERALAGENCY <br /> TYPE OF aUSINESS Q I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITEE.P.A I.D.a(aWww/ <br /> ] FARM Q a PROCESSOR 5 OTHER I' RESERVATION <br /> OR TRUST LANDS 7—- <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCYCONTACT PERSON (SECONDARY)-option&[ <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE <br /> DAYS: NAME MST,FIRST <br /> _p PHONE 0 WITH AREA CODE <br /> .I . S� �` _� 3� 7 , <br /> NIGHTS: NAME( IRST) / PHONE A WITHAREA CODE NIGHTS: NAME(LAST.FIRST) <br /> -- - PHONE s WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION•JMUST BE COMPLETED <br /> NAME <br /> SL <br /> -In,( S T <br /> CARE OF ADDRESS INFORMATION S „ c} <br /> MAILING OR STREET ADDRESS ✓ EOA nMMlala <br /> INDIVIDUAL Q LOCAL.AGENCY Q STATE-AGENCY <br /> CITY NAME CORPORATION = PAgTNEA$HP O COUNTYAGENCY Q FED <br /> ERA <br /> L-AGENCY <br /> STATE I ZIP CODE I PHONE E WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED <br /> NAME Of OWNER CARE GF ADORES$INFORMATION <br /> MNLWG OR STREET ADOpES3 ✓ Ynaitaa <br /> O INpVxX1AL [j LOCAL.AGENCY Q STATE-AGENCY <br /> CITY NAME =]CORPORATION Q PARTNERSHIP Q COURN AGENCY Q RMERALAGENCY <br /> 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-f-41- S (� <br /> 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I. 11.[D IILQ <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 <br /> GATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION t FACILITY A <br /> S?0 Cl-3 U <br /> =T� <br /> LOCATION CODE -OPnOML CENSUS TRACT -OPrAOML SUPiii;OR-OLSTRICT CODE -OPTAONAL <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(g90) <br /> FORMAA2 <br />