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eezoun es <br /> STATE OF CALIFORNIA e t <br /> STATE WATER RESOURCES CONTROL BOARD ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� <br /> COMPLETE THIS FORM FOR EACH FACILITYISRE .��.o�r�. <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT F7) 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> AD01rl Ca <br /> ADDRESS NEAREST CflO535TREET PARCELa(OPTDNAU <br /> 717 <br /> CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE <br /> 9tv cA YSZa <br /> TO INDIICCATE CORPORATION D INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY STATE AGENCY (_1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTA13UTORpV IF INDIANATION #OF TANKS AT SITE E.P.A. I.D.#(opfimap <br /> Q 3 FARM Q 4 PROCESSOR �6 OTHER OR TRUST LANDS `J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ W' ate I= INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> .. D. ; 116 <br /> CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NNAAAMME GTT ZIP CODE <br /> qr5r PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> n! RVD12_iP l6- Co <br /> MAILI OR STREET ADDRESSicare <br /> /' = INDIVIDUAL QLOCAL-AGENCY OSTATE-AGENCY <br /> . 0 v CORPOMTION 0 PARTNERSHIP 0 COUNTY-AGENCY E__I FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> t4- <br /> cw- g52a <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ [41-4]-� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O II. It.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN CORRECT <br /> APPUCANTSNAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> owl s70-,e­KZ7 <br /> LOCATION CODE -OPTIONAL CENSU�'RAC OPTIONAL S��31STRICT CODE -OPTIONAL Ice <br /> 415D <br /> THIS FORM MIST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(490) <br /> FORWA1A.R2 <br />