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STATE OF CAUFORWA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACIL TVISITE <br /> MARKO;�I,�IyI'Y Q 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br /> FQ <br /> ONE ITEIM 2 INTERIM PERMIT 0 4 AMENDED PERMIT <br /> 0 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8,ADDRESS-(MUST BE COMPLETED) <br /> DS FACILITY NAME <br /> NAME OF OPERATOR <br /> L <br /> ADDR SS <br /> NEAREST CROSS STREET PARCEL#(OPTONAL) <br /> Cl NAME , STATE ZIP CODE <br /> SITE PHONE 1 WITH AREA CODE <br /> v BOX CA gS <br /> Unl <br /> TOINDCATE WCORPDRATKIN 0 INDIVIDUAL ED PARTNERSHIP LOCAL-AGENCY ` — _ <br /> DISTRICTS �UNfY-AGENCY gTATE-AGENCY FEDEMLy1GENCY <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTORN SOF TANKS AT SITE E.P.A L D.s(apbW) <br /> O 3 FARM O 4 PflOCESSOR Q 5 DITHER=SERVATION <br /> 01 <br /> s <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONES WITH AREA CODE <br /> DR <br /> N M (LAS ,FIRST) IP ONE`*,WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> t <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> E CARE OF ADDRESS INFORMATION <br /> Cmk�lti <br /> CNG OR STREET ADDgESS ✓/bow blMko I0 INDIVIDUAL Q LOCAL AGENCY 0 STATEAGBICY <br /> O s(� ��I CORPORATION 11 PARTNERSHIP COUNTY,AGENCY E3 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CDOE PHONE S WITH AREA CODE <br /> SOLC. 6A Il L _ <br /> III. TANK OWNER JNFORMATION- MUST BE COMPLETED <br /> E FOWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ,V Wxbirld u I=INDIVIDUAL Q LOCAL-AGENCY (] STATE AGENCY <br /> 4; 9 `l L'7 CORPORATION 0 PARTNERSHIP COUNTYAMMCY = FEDEAALAGENCY <br /> CI NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> b Cl S?- - Zo <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739.2582 if questions arise. <br /> TY(TK) HQ 4 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O it.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST CFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> (CANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COU®h^,Y i JURISDICTION S FACILITY S <br /> �� <br /> LOCATION COQE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -Q°TKINAL <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(49)) FORMA 12 <br /> ��G <br /> 0 <br /> low <br /> �' <br />