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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY T NEW PERMIT O 3 RENEWAL PERMIT E 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE 5-2 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FAC ITY NAME / / NAME OF OPERATOR <br /> /-e rolls7Y✓CRCwl to amts � k <br /> ADDRESS [//� NEAREST CROSS STREET CEL#(OPTIOW <br /> !;00 S• I4 ajI PAR <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> (-crncIn C'�•�1 CA 523 gZ— V7 SU <br /> I/ BOX <br /> TOINDICATE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL AGENCY COUNTYAGENCY 0 STATE-AGENCY <br /> DISTRICTS O FEDEAAL-AGENCY <br /> TYPE OF BUSINESS 0 t GAS STATION Q 2 DISTRIBUTOR 0RESERVATION <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.M#(ROk") <br /> D <br /> 0 3 FARM 0 4 PROCESSOR 0 5 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 i WITH AREA CODE <br /> v Otv Yck i-y SU <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 /> Coldni�c S _VC_`r � l �c7 <br /> MAILING OR TM; #ET REBS ✓bwbirldl 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> ll 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATTS� ZIPCODE PHONE#WITH AREA CODE <br /> I,Ja4sr� Vi ie C4 S t77 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER C' CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS WX In Baca D INDIVIDUAL D LOCAL-AGENCY O STATEAGENCY <br /> 0 CORPORATION O PARTNERSHIP COUNTY-AGENCY D 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) Hp 4 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.O II.L?� III.r7 <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 MONTHIDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORMA-112 <br /> FORM A(9-W) <br />