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4t <br /> STATE OF CALIFORNIA `y <br /> STATE WATER RESOURCES CONTROL BOARD ' 'o <br /> UNDERGROUND STORAGE TANK DERMIT APPLICATION - FORM A "mom <br /> COMPLETE THIS FORM FOR EACH fWLITYISITE <br /> MARK ONLY 1 NEW PERMIT J 3 RENEWAL PERMIT S CHANGE OF INFORMATION O 7 PERM CLOSED SffE <br /> ONE ITEM 2 INTERIM PERMIT '_I A AMENDED PERMIT S TEMPORARY SITE CLOSURE S3 <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Schu /tr <br /> ADDRESS NEAREST CROSS STREET PARCELO(OPTIONAU <br /> GY. C{J <br /> CITY NAME STATECODE SITE PHONE s WITH AREA CODE <br /> S� CBOX A ZIP fL <br /> TO INMATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHP Q UOCAL TAGENCY Q COUNTYAGENDY Q STATEAGENCY Q FEWARL.AGENCY <br /> DISTRITYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN s OF TANKS AT SITE E.P.A. L D.s(op!I <br /> RESERVATION <br /> Q 3 FARM Q A PROCESSOR 2fs OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME T,FIRST) _ PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> S ti f/ <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA NKGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5-19- <br /> MAILING OR STREET ADDRESS bot binAlcAN Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION. Q PARTNERSHIP Q COUNTYAGENCY Q FEDERALAGENDY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER 5/)-- <br /> CAREOFADORESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box III W 19M Q INOWDUAL Q LOCAL-AGENCY Q STATEAGENCV <br /> Q CORPORATION Q PARTNERSHIP Q COUNrYAOENDY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-F4 - Q 3 a <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or GI's checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L El 11.ED 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 A SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY JURISDICTION FACILITYLF--S/7 <br /> as7 <br /> LOCATION CODE -OPTIONAL CENSUSTRACTA -OPTIONAL sUPV13OR-DISTRICTCDDE -OPrX)NAL <br /> 3 <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(fief) FORA A2 <br />