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A t� <br /> ,%W STATE OF CALIFORNIA `00 <br /> STATE WATER RESOURCES CONTROL BOARD A mom, a <br /> C UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A ° <br /> COMPLETE THIS FORM FOR EACH F ILITYISITE <br /> MARK ONLY T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 0 6 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE 98 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> �A OR FACILITY NAM NAME OF OPERAT R <br /> L1 In ni�ea( Salt"//�/6f - f 0 a lzans <br /> ADD ESS N EST CROSS S_ JREE,f PARCEL#(OFrgNAL) <br /> Zl <br /> STACA 21PC�E6 3 PHONEi WITH AREA <br /> Box <br /> TOINDCATE O CORPORATION E:l INDIVIDUAL 0 PARTNERS14P E:] LOCAL.AGFNCY Q COUNrYAGENCY ED STATE-AGENCY 0 FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q T GAS STATION Q 2 DISTRIBUTORD RE/ IF INDIAN SERVATION s OF TANKS AT SITE E.P.A. L D.S(optima) <br /> 0 3 FARM Q I PROCESSOR 5 OTHER OR TRUST LANDS 13 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> S:7j,7E((L.ASSTT,�Tn 1d17 PHONE S WITH AREfCODE _ DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS:NAME( T,FI''RS,, PHONE s WITH MEA lJ�7/T'J NIGHT$: NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> Tglt'S ve �tY>za� -p9 *Z- /� <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NjMECARE OF ADDRESS INFORMATION <br /> /1740I /J 4,1d 61&I 75-/?'t Gf <br /> MAILING 14 STREET ADDR S Q ✓ bQKIDV4t =1 INDIVIDUAL 0 LOCAL-AGENCY Q STATEAGURN <br /> 20 /O <br /> E3 CORPORATION ED PARTNERSHIP [:] COUNTY-AGENCY Q FEDERAL-AGENCY <br /> AREA CODE <br /> CITY A E n 9Tr (/1✓q ZIP of CZO-4 IFHONE S WITH <br /> L�v� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNERn CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Ow DIMIAM 0INDIVIDUAL EDLOCAL.AGENCY EDSTATE-AGENCY <br /> (�CORPORATION 0 PARTNERSHIP COUMY.AGENCY = FEDERAL,AGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-74 -1 1 1 1771 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is c cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.EPT, III.❑ <br /> THIS FORM HAS SEEN 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 MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY• JURISDICTION# FACILITY Y <br /> ® Z1A1C© Co � 2 <br /> LOCATION -OPTIONAL CENSUS TRACT OPTIONAL SUPVISOR•DISTRICT CODE -OPTIONAL <br /> 23. d 2 <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(9.90) FOR0037AA2 \�(\ <br /> \J-) <br />