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r'de�rNnnB pp <br /> `� STATE OFCAUFORNIA *. ' <br /> i <br /> STATE WATER RESOURCES CONTROL BOARD i mom, a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> ��/ 11,p.Mn. <br /> COMPLETE THIS FORM FOR EAC ACILITYISRE <br /> MARK ONLY E:] T NEW PERMIT O 3 RENEWAL PERMIT EOS CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE REM F-1 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA 01WILITY NAV NAME OF OPERATOR <br /> AD DR SS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME r STATE ZIP CODE Lo CA � f O STEO #33R 'I/ Box COOE� <br /> TOIN GTE CORPORATION INDIVIDUAL O PARTNERSHIP (]DISTRICTS <br /> LOCAL-AGENCY O COUNTY-AGENCY f�STATE-AGENCY 0 FEDERALAGENCY <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTORp V IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opUmM) <br /> O ON <br /> 3 FARM O 4 PROCESSOR I OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY ' NAME( T,FIRST) j'HON'E# ITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> 0 CaV <br /> NIGHTS: N E(LAST, ST) PHONES V91TH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUS BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa bbxlwaN 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> (]CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION• MUST BE COMPL D) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bwbw1cm O INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> (�CORPORATION O PARTNERSHIP (] COUNTYAGENCY 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) HO K41- 1 F <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless x I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.mz 11.O III.0 <br /> T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEANO CORRECT <br /> APPLICANTS NAME 1PRINTED&SIGNATURE) APPLICANTS TIRE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY Tg_�Io 33 <br /> COUNTY a JURISDICTION# F�A�CIILLM (��� /�� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL u� <br /> a— _ I�� <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=3A-R2 <br /> FORM A(9-90) <br />