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eyaun < <br /> co <br /> STATE OFCAUFOR14A � L <br /> N <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> ��4•peMJ <br /> 1 COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY T NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Gf/L 6D eD - <br /> ADDRESS N�ESTCROSSSTREET PARCEL k(OFrIDNAL) <br /> ZZ> p�1pwA4 rytrtml <br /> CITY NAME STATE ZIP CODE SITE PHONE sITH AREA CODE <br /> 4Z <br /> CA D 14(67-- 96;0 <br /> ✓ BO% CORPORATION O INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY O STATE-AGENCY FEDEML-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR Q R✓SERVATIOONN k OF TANKS AT SITE E.P.A. L D.k(apNmel) <br /> O 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS O <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE k WITH AREA DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> AAND 2,003 �- D <br /> NIGHTS: NAME(LAST,FIRST) PHONES WITH AREA CODE NIGHTS' NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓jnxb Wkau D INDIVIDUAL =1 LOCAL-AGENCY O STATE AGENCY <br /> po- CICORPOMTION PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CIN NAME STATE- ZIP?5 PHONE oWITH AREA CODE WT <br /> yu <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED G� , Y/62 OG�� G/ <br /> NAME OF OWNER CARE OF ADDRESS INFORMATK)N <br /> feeoam-r ez> <br /> MAILING OR STREET ADDRESS _AM bUIDIM110 INDIVIDUAL f� LOCAL AGENCY STATE AGENCY <br /> /*70 " [!W/L[�� POMTION O PARTNERSHIP Ij COUNrVAGENCY O FEDERAL-AGENCY <br /> CITY NAME * STATE ZIP CODE P E s WITH AREA CODE <br /> s� cid- 45z� cz�) 962 -Ss v <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739.2582 if questions arise. <br /> TY(TK) HQ F4-T-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.0 II.EX III. <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN Y# JURISDICTION# FACILITY It <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> LET- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. \ <br /> FOROMM-R2 <br /> FORMA(490) \ x/ <br />