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X fe <br /> � STATE OF CALIFORNIA 1 `OM1 <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> o� <br /> COMPLETE THIS FORM FOR EACH F&MIfYISSITE <br /> MARK ONLY F-1 i NEW PERMIT O 3 RENEWAL PERMIT EIrS CHANGE OF INFORMATION O 7 PER ANENTLY C <br /> ONE ITEM Q 2 INTERIM PERMIT E::) A AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME - NAMEOFOPERATOR <br /> ADDRESS NEARESTCROSSSTREET PARCELS(OPTIONAL) <br /> CIN NAME STATE ZIP CODE SITE PHONE S WITH AREA CODE <br /> I/ BOX I <br /> G CA G/ — s— 79— <br /> TOINpCACA <br /> TE O CORPORATION O INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTYAGENCV O STATE AGENCY 0 FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O ( GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN S OF TANKS AT SITE E.P.A. L D.#(opfimell) <br /> Q 3 FARM Q 6 PROCESSOR RESERVATID <br /> OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST)19/0 <br /> L PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> `0 - <br /> NIGHTS: NAME( ,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONES WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bwbb9cm Q INDIVIDUAL I= LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP =COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITHAREACODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bubMeNe INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> O CORPORATION PARTNERSHIP ODUNTY-AGENCY Q FEDERAL-AGENCY <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 quesfions arise. <br /> TY(TK) HQ 4 4 -`h�`� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.[71 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR WTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# ':�PIA)6/0 <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 3S--V 3 A3 <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(490) FOR Wi5a-R2 <br /> 1 <br />