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STATE OF CALIFORNIA .g 's- <br /> STATE WATER RESOURCES CONTROL BOARD 3y 'c '� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� �a <br /> �: o <br /> COMPLETE THIS FORM FOR EACH FACILITY(SRE <br /> MARK ONLY I� 1 NEW PERMIT E--] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 'J 2 INTERIM PERMIT 77 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE S- <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME /—/ NAME OF OPERATOR_ <br /> - <br /> ADDRESS NEAREST CROSS STREET PARCEL A(OPMML) <br /> /b f6 ,Kl BrvacPc. <br /> CITY NAME / STATE ZIP CODE 917E PHONE 4 WITH AREA CODE <br /> /N- CA Yes -36v 7, <br /> TOA <br /> INDICATE p CORPORATION p INDIVIDUAL p PARTNERSHIP p IDC,t4AGENCY p COUNTY-AGENCY p STATE AGe1C/ p FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q O GAS STATION Q 2 DISTRIBUTOR pRESERVATID <br /> '/ IF INDIAN ISOF TANKS AT SRTE E.P.A L O.S(opioW <br /> p 3 FARM O A PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE <br /> 4 sl, <br /> NIGHTS: NAME(LAST.FIRS PHONE S WITH AREA CODE N04TS: NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME /` CARE OF ADDRESS INFORMATION <br /> 4; c k,- l <br /> MAILING OR STREET ADDRESS ./ bbwKa p ISDIylOUAI p LOCAL-AffNLY pSTARE-AGENCY <br /> p CORPORATION p PARTNERSHIP p CONrY,LGENCY p FEDERALAGENCY <br /> CITY NAME / STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS IN�F^ORMATION <br /> //" <br /> l- 4 c Cs.v lKL cr� ! C7 1f l�. <br /> MAILING OR STREET ADDRESS / n ✓ =bYNIMP p SgVp((AL p LOCAL-AGFNCY p STATEAGENCY <br /> /c 3 e- C44 h �p,V �t p CORPORATION p PARTNERSHIP p CWNNADENCY p FEDEPALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE S PATH AREA CODE <br /> SLo C9 I 7^SLuS 00 Sc'0 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ4 4 - 0 3 (o <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: 1.a 11.0 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(PR NTED a SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY <br /> s FACIL 5- <br /> lFT—F# JURISDICTION 7 <br /> LOCATION CODE -OPTPOADIL CENBUB TRACTS -OPTIOONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0/ 2 ?OFv 3 s Co rr <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(fWO FOROMMA2 f <br />