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't50VR f3 <br /> CV <br /> STATEOFCAUFORWA :` �i <br /> STATE WATER RESOURCES CONTROL BOARD i - ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A � vj <br /> c � . <br /> ,ROR�,. <br /> COMPLETE THIS FORM FOR EA FACILRYISRE <br /> MARK ONLY O T NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE SRE <br /> ONE REM � 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> D ORFACI TYN ENAMEOFOPERATOR <br /> Kai " e-Fe'!!5 U�� on <br /> ADDRESS NEARES CROSS REET PARCEL#(OP(OPTIONAL) <br /> CIN NA STATE ZIP IT�EpHONEYWITHpREACODE <br /> CA 52C) 61J1- 6PE4'ittln A I fll <br /> ✓ BOX CORPORATION INDIVIDUAL D PMTNERSHIP QLOCAL-AGENCY Q COUNTY-AGENCY STATE AGENCY O FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN *OF TAN AT SITE E.P.A. I.D.IF(GpOmal) <br /> O RESERVATION <br /> = 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST, PHONEt WITH AREACODE DAYS: NAME(LAST.FIRSn PHONE4 WITH AREA CODE <br /> NIGHTS: NAME(LPHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION•IMUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓�v bNbcaN f� INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE*WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bo+101rdute [] INDIVIDUAL LOCAL AGENCY O STATE AGENCY <br /> 0 CORPORATION PARTNERSHIP O COUNTY-AGENCY [--] FEDERAL-AGENCY <br /> CITY NAMESTATE 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) HQ [4T4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or RI is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O II.[1] 111.0 1 <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# c&r JURISDICTION# FACILITY# <br /> Sq 1 © o al <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> OI1 23• BD 321 VY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLYFOR0n�Ta-Pz <br /> FORM A(9-90) \ <br />