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a <br /> STATE OF CALIFORNIA �A STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> CCOMPLETE THIS FORM FOR EACH FACILrfYBRE <br /> MARK ONLY 0 t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANCE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S-3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Grou.'t as IV 40v/e. <br /> ADDRESS Ad <br /> , NEAREST OSSSTREET PARCEL#(OPrK)NAL) <br /> O$DO S, hf'�a.J I�jt <br /> CITY NAME STATE ZIP CODE <br /> SITE PHONE#W NTH AREA CODE <br /> nA a CA to?- <br /> BOX <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTYAGENCY Q STATE.AGENCY Q FEDEMLAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR / IF INDIAN If OF TANKS AT ITE E.P.A. I.D.#(aptknO <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ov eGRe ?d9-9g2 -Ylsa <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA—CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bkdk.W Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Q INDIVIDUAL LOCAL AGENCY Q gTATEAGENCYe <br /> COR <br /> Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - 3 2 Z <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.5z it.Q 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 MONTHIDAWVEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> W � � 6R,wrio <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 4� 2 , s� zS- y/y <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 /> FOR=3AA2 <br /> FORM A(5-90) //��// /✓^// <br />