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•� <br /> STATE OF CAl1FORWA .`•e > <br /> STATE WATER RESOURCES CONTROL BOARD �� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 3- � oe <br /> O-Y.Y <br /> COMPLETE THIS FORM FOR EAC ACILITYISRE <br /> MARK ONLY O 1 NEW PERMIT E:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY RE <br /> ONE REM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR CILITV NAME _ NAME OF OPERATOR <br /> C O <br /> ADDRESS LNI, NEARE T RO STREET PARCELs(OPTIDNAI) <br /> rCITY NAME ^ ST ZIP CODE SITE PHONE N WITH AREA CODE <br /> J CA <br /> To INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTYAGENCY Q STATEAGENCY Q FEDEML#GENCY <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q q SERFINVA10, VDTION s OF TANKS AT SITE E.P.A L D.s(cprbwp <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> U. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CAREOFA DRESS FORMATION <br /> r r S ° <br /> MAI I OR STREET DR SS hMeale Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> / CORPONATION Q PARTMERfRIP Q CWNTYAGENCY Q FEDERAL-AGENCY <br /> CITUAMFz 3T TE ZIP CODE PHONE S WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> a/ <br /> MAILING OR STREET ADDRESS I bm NlndlcaN Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q CWNrY-AGENCY Q FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE s 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 -1 1 1 1 1 —U <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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Q II. III.O <br /> THIS FORM HAS BEENCOMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF UY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY A JURISDICTION# FACILITY• <br /> LOCATION CODE -OPTIONAL CENSUS RACT -OPTIONAL SUPVI30R-DISTRICT CODE '7A <br /> THIS <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 /> FORMA A2 <br /> FORM A(B-BO) <br />