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-�so�- e <br /> STATE OF CAUPORNIA �� <br /> STATE WATER RESOURCES CONTROL BOARD ;m� a e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , a� <br /> \t ,� ��4nonMJ <br /> --11 COMPLETE THIS FORM FOR EACH FACIUTYISITE <br /> MARK ONLY LJ I NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION Yf 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE 5 a <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFA ILITYNAME NAME OF OPERATOR <br /> G. <br /> ADDRESS NEAREST CROSS STREET PARCEL)(OPrIONAL) <br /> D F <br /> CITY NAME ,J ♦ STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> L10 (/�y��2i CA D <br /> ✓ <br /> BOX TOINDICATCORPORATIONOISTATE AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(ap1kW <br /> RESERV, <br /> 0 3 FARM Q 4 PROCESSOR 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#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ bar blidem Q INDIVIDUAL 0 LOCAL-AGENCY D STATE-AGENCY <br /> • L 0 CORPORATION D PARTNERSHIP Q COUNrYAGENCY O FEDERAL-AGENCY <br /> CI NAME r 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 bwwlndla INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> D CORPORATION O PARTNERSHIP COuMY#GENCY FFOERALAGENCY <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) HO K41- <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.(-D II. III.O <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 WTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY N. 'S <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1 FIT # <br /> LOCATION CODE -OPTIONAL CENSUS TRACT& -OPTMNAI, $UPVISOR- RIOT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, -'LESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOR <br /> FORM A(9-90) v/,l MA R2 `'pj� <br />